Provider Demographics
NPI:1043586605
Name:NIFONG, NANCY ALEXIS (MD)
Entity Type:Individual
Prefix:
First Name:NANCY
Middle Name:ALEXIS
Last Name:NIFONG
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:ALEXIS
Other - Middle Name:
Other - Last Name:FULK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:5350 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27107-9174
Mailing Address - Country:US
Mailing Address - Phone:336-784-0505
Mailing Address - Fax:336-784-5031
Practice Address - Street 1:5350 S MAIN ST
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27107-9174
Practice Address - Country:US
Practice Address - Phone:336-784-0505
Practice Address - Fax:336-784-5031
Is Sole Proprietor?:No
Enumeration Date:2012-03-28
Last Update Date:2021-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2015-01766207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine