Provider Demographics
NPI:1417427188
Name:PICKENPACK-COUSAR, ATHENA NICOLE (NP)
Entity Type:Individual
Prefix:MRS
First Name:ATHENA
Middle Name:NICOLE
Last Name:PICKENPACK-COUSAR
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1737
Mailing Address - Street 2:
Mailing Address - City:JAMESTOWN
Mailing Address - State:NC
Mailing Address - Zip Code:27282-1737
Mailing Address - Country:US
Mailing Address - Phone:336-543-8212
Mailing Address - Fax:
Practice Address - Street 1:1200 N ELM ST
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27401-1004
Practice Address - Country:US
Practice Address - Phone:336-832-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-26
Last Update Date:2021-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5011168363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner