Provider Demographics
NPI:1619596772
Name:MERRITT, MARK AUSTIN (CRNP)
Entity Type:Individual
Prefix:
First Name:MARK
Middle Name:AUSTIN
Last Name:MERRITT
Suffix:
Gender:M
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3610 BUSH ST
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27609-7511
Mailing Address - Country:US
Mailing Address - Phone:919-876-3130
Mailing Address - Fax:
Practice Address - Street 1:3610 BUSH ST
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27609-7511
Practice Address - Country:US
Practice Address - Phone:877-876-3783
Practice Address - Fax:855-420-6402
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-09
Last Update Date:2022-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-173916163W00000X
NC5015132363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse