Provider Demographics
NPI:1639226418
Name:REARDON, LECIA WOOTEN (NP)
Entity Type:Individual
Prefix:MRS
First Name:LECIA
Middle Name:WOOTEN
Last Name:REARDON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:340 SEMINARY ST
Mailing Address - Street 2:
Mailing Address - City:KENANSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28349-8978
Mailing Address - Country:US
Mailing Address - Phone:910-296-2130
Mailing Address - Fax:910-296-0252
Practice Address - Street 1:340 SEMINARY ST
Practice Address - Street 2:
Practice Address - City:KENANSVILLE
Practice Address - State:NC
Practice Address - Zip Code:28349-8978
Practice Address - Country:US
Practice Address - Phone:910-296-2130
Practice Address - Fax:910-296-0252
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-04
Last Update Date:2019-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC201848363L00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner