Provider Demographics
NPI:1497435663
Name:RICHARDSON, JUSTIN KYLE (FNP-C)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:KYLE
Last Name:RICHARDSON
Suffix:
Gender:M
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1301 FAYETTEVILLE ST
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27707-2398
Mailing Address - Country:US
Mailing Address - Phone:919-956-4000
Mailing Address - Fax:
Practice Address - Street 1:1301 FAYETTEVILLE ST
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27707-2398
Practice Address - Country:US
Practice Address - Phone:919-956-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-21
Last Update Date:2023-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5018504363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily