Provider Demographics
NPI:1689332876
Name:LIFE MIND ALLIANCE
Entity Type:Organization
Organization Name:LIFE MIND ALLIANCE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTITIONER
Authorized Official - Prefix:
Authorized Official - First Name:LARISA
Authorized Official - Middle Name:ROLLINS
Authorized Official - Last Name:KING
Authorized Official - Suffix:
Authorized Official - Credentials:PMHNP-BC
Authorized Official - Phone:336-202-3486
Mailing Address - Street 1:1704 MILAN RD
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27410-3026
Mailing Address - Country:US
Mailing Address - Phone:336-202-3486
Mailing Address - Fax:
Practice Address - Street 1:407 E FREMONT ST
Practice Address - Street 2:
Practice Address - City:BURGAW
Practice Address - State:NC
Practice Address - Zip Code:28425-5129
Practice Address - Country:US
Practice Address - Phone:336-202-3486
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-12-04
Last Update Date:2021-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty