Provider Demographics
NPI:1629090998
Name:DOUGLAS, JANICE M (AA)
Entity Type:Individual
Prefix:
First Name:JANICE
Middle Name:M
Last Name:DOUGLAS
Suffix:
Gender:F
Credentials:AA
Other - Prefix:
Other - First Name:JANICE
Other - Middle Name:M
Other - Last Name:KOZIOL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:AA
Mailing Address - Street 1:411 EMERALD LANDING DR
Mailing Address - Street 2:
Mailing Address - City:EMERALD ISLE
Mailing Address - State:NC
Mailing Address - Zip Code:28594-2407
Mailing Address - Country:US
Mailing Address - Phone:440-289-5253
Mailing Address - Fax:
Practice Address - Street 1:3714 GUARDIAN AVE STE W
Practice Address - Street 2:
Practice Address - City:MOREHEAD CITY
Practice Address - State:NC
Practice Address - Zip Code:28557-2975
Practice Address - Country:US
Practice Address - Phone:252-648-0409
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2021-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1000-00835367H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH000000232159OtherUNISON
OH430027428OtherRAILROAD MEDICARE
OH414964OtherWELLCARE MEDICAID
OH7758969OtherAETNA
OH0583328OtherBCMH
OH000000515963OtherANTHEM
OH2268264Medicaid
OH0583328OtherBCMH
OH414964OtherWELLCARE MEDICAID