Provider Demographics
NPI:1639704828
Name:WILLINGHAM, DANIEL B (CRNA)
Entity Type:Individual
Prefix:
First Name:DANIEL
Middle Name:B
Last Name:WILLINGHAM
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5210 SWITCHBACK DR
Mailing Address - Street 2:
Mailing Address - City:HIGH POINT
Mailing Address - State:NC
Mailing Address - Zip Code:27265-2934
Mailing Address - Country:US
Mailing Address - Phone:336-688-4917
Mailing Address - Fax:
Practice Address - Street 1:401 FERNDALE BLVD
Practice Address - Street 2:
Practice Address - City:HIGH POINT
Practice Address - State:NC
Practice Address - Zip Code:27262-4739
Practice Address - Country:US
Practice Address - Phone:336-882-2567
Practice Address - Fax:336-882-5466
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-08
Last Update Date:2022-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC278024163W00000X
390200000X
NC138480367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program