Provider Demographics
NPI:1639823784
Name:SPANN, ESTELLA JOANN
Entity Type:Individual
Prefix:MR
First Name:ESTELLA
Middle Name:JOANN
Last Name:SPANN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1136 BERTHA WILSON RD
Mailing Address - Street 2:
Mailing Address - City:BLANCH
Mailing Address - State:NC
Mailing Address - Zip Code:27212-9795
Mailing Address - Country:US
Mailing Address - Phone:336-694-1878
Mailing Address - Fax:336-694-1878
Practice Address - Street 1:1136 BERTHA WILSON RD
Practice Address - Street 2:
Practice Address - City:BLANCH
Practice Address - State:NC
Practice Address - Zip Code:27212-9795
Practice Address - Country:US
Practice Address - Phone:336-694-1878
Practice Address - Fax:336-694-1878
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-08
Last Update Date:2022-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NM0170583104A0625X
NC0170583104A0630X, 310500000X, 310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
No3104A0625XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Mental Illness
No3104A0630XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Behavioral Disturbances
No310500000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Mental Illness
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC017058OtherFACILITY LICENSE NUMBER