Provider Demographics
NPI:1578109427
Name:SAULTER, MIA LICOLE (AGPCNP)
Entity Type:Individual
Prefix:
First Name:MIA
Middle Name:LICOLE
Last Name:SAULTER
Suffix:
Gender:F
Credentials:AGPCNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2150 NC HIGHWAY 65
Mailing Address - Street 2:
Mailing Address - City:REIDSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27320-9609
Mailing Address - Country:US
Mailing Address - Phone:336-427-9022
Mailing Address - Fax:336-427-9030
Practice Address - Street 1:2150 NC HIGHWAY 65
Practice Address - Street 2:
Practice Address - City:REIDSVILLE
Practice Address - State:NC
Practice Address - Zip Code:27320-9609
Practice Address - Country:US
Practice Address - Phone:336-427-9022
Practice Address - Fax:336-427-9030
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-25
Last Update Date:2024-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5012986363L00000X, 363LG0600X, 363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology