Provider Demographics
NPI:1629494265
Name:FAYETTEVILLE ADVANCED PRACTITIONERS
Entity Type:Organization
Organization Name:FAYETTEVILLE ADVANCED PRACTITIONERS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTITIONER, OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JAMIE
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:DICKERHOFF
Authorized Official - Suffix:
Authorized Official - Credentials:FNP-BC
Authorized Official - Phone:910-670-2047
Mailing Address - Street 1:2915 RAEFORD RD
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28303
Mailing Address - Country:US
Mailing Address - Phone:910-670-2047
Mailing Address - Fax:
Practice Address - Street 1:2915 RAEFORD RD
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28303-5508
Practice Address - Country:US
Practice Address - Phone:910-670-2047
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2014-03-06
Last Update Date:2014-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC164680363LA2200X
NC148570363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC245538461OtherNPI
NC1386970572OtherNPI