Provider Demographics
NPI:1477754646
Name:HARRIS, ILA GERTRUDE
Entity Type:Individual
Prefix:MRS
First Name:ILA
Middle Name:GERTRUDE
Last Name:HARRIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1017 HWY 158
Mailing Address - Street 2:
Mailing Address - City:ROUGEMONT
Mailing Address - State:NC
Mailing Address - Zip Code:27572
Mailing Address - Country:US
Mailing Address - Phone:919-693-7591
Mailing Address - Fax:
Practice Address - Street 1:1017 HWY 158
Practice Address - Street 2:
Practice Address - City:ROUGEMONT
Practice Address - State:NC
Practice Address - Zip Code:27572
Practice Address - Country:US
Practice Address - Phone:919-693-7591
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCFCL-039-002376G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376G00000XNursing Service Related ProvidersNursing Home Administrator