Provider Demographics
NPI:1023556461
Name:DEDEAUX, DARRELL LEE (NP-C)
Entity Type:Individual
Prefix:
First Name:DARRELL
Middle Name:LEE
Last Name:DEDEAUX
Suffix:
Gender:M
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:129 T.T. LANIER STREET
Mailing Address - Street 2:
Mailing Address - City:BUIES CREEK
Mailing Address - State:NC
Mailing Address - Zip Code:27506
Mailing Address - Country:US
Mailing Address - Phone:910-893-1562
Mailing Address - Fax:910-814-5727
Practice Address - Street 1:380 KNOLLWOOD ST # 505
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-1884
Practice Address - Country:US
Practice Address - Phone:833-357-2966
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-02-06
Last Update Date:2019-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC116077363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care