Provider Demographics
NPI:1669469250
Name:PROFESSIONAL NURSING SERVICE, INC
Entity Type:Organization
Organization Name:PROFESSIONAL NURSING SERVICE, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:BETTY
Authorized Official - Middle Name:WOOLARD
Authorized Official - Last Name:WALLACE
Authorized Official - Suffix:
Authorized Official - Credentials:RN, MSN, PNP
Authorized Official - Phone:252-247-6911
Mailing Address - Street 1:212 N 35TH ST
Mailing Address - Street 2:
Mailing Address - City:MOREHEAD CITY
Mailing Address - State:NC
Mailing Address - Zip Code:28557-3104
Mailing Address - Country:US
Mailing Address - Phone:252-247-6911
Mailing Address - Fax:252-247-1034
Practice Address - Street 1:212 N 35TH ST
Practice Address - Street 2:
Practice Address - City:MOREHEAD CITY
Practice Address - State:NC
Practice Address - Zip Code:28557-3104
Practice Address - Country:US
Practice Address - Phone:252-247-6911
Practice Address - Fax:252-247-1034
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-09-29
Last Update Date:2009-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCHC1437251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC3407219Medicaid
NC3408380Medicaid
NC6800224Medicaid
NC6800226Medicaid
NC6800225Medicaid
NC6800227Medicaid
NC7100074Medicaid
NC6600179Medicaid
NC6600180Medicaid
NC7100075Medicaid
NC6600178Medicaid
NC720297VMedicaid
NC7701469Medicaid
NC6600207Medicaid
NC6600495Medicaid
NC6800356Medicaid
NC7100073Medicaid
NC7100078Medicaid
NC7100075Medicaid
NC347219Medicare ID - Type UnspecifiedHOME HEALTH