Provider Demographics
NPI:1215385463
Name:PROSPER AT HOME HEALTH CARE SERVICES LLC
Entity Type:Organization
Organization Name:PROSPER AT HOME HEALTH CARE SERVICES LLC
Other - Org Name:PREMIUM DIRECT MEDICAL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:MANAGING DIRECTOR/HEAD NP
Authorized Official - Prefix:MRS
Authorized Official - First Name:SHAWANDA
Authorized Official - Middle Name:LESTER
Authorized Official - Last Name:SPENCER
Authorized Official - Suffix:
Authorized Official - Credentials:NP-C
Authorized Official - Phone:704-907-0537
Mailing Address - Street 1:7319 YELLOWHORN TRL
Mailing Address - Street 2:
Mailing Address - City:WAXHAW
Mailing Address - State:NC
Mailing Address - Zip Code:28173-7465
Mailing Address - Country:US
Mailing Address - Phone:704-907-0537
Mailing Address - Fax:
Practice Address - Street 1:7319 YELLOWHORN TRL
Practice Address - Street 2:
Practice Address - City:WAXHAW
Practice Address - State:NC
Practice Address - Zip Code:28173-7465
Practice Address - Country:US
Practice Address - Phone:704-907-0537
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-05-27
Last Update Date:2016-05-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCF0516317363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty