Provider Demographics
NPI:1629552567
Name:PHELAN, MARY THERESE (FNP)
Entity Type:Individual
Prefix:
First Name:MARY THERESE
Middle Name:
Last Name:PHELAN
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9318 LENNOX LAUREL CIR
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27617-2068
Mailing Address - Country:US
Mailing Address - Phone:919-924-4171
Mailing Address - Fax:
Practice Address - Street 1:815 OBERLIN RD
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27605-1300
Practice Address - Country:US
Practice Address - Phone:919-322-4722
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-17
Last Update Date:2018-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5010958363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily