Provider Demographics
NPI:1710394226
Name:PROVENCE, SUNNY (FNP)
Entity Type:Individual
Prefix:
First Name:SUNNY
Middle Name:
Last Name:PROVENCE
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:SUNNY
Other - Middle Name:
Other - Last Name:PROVENCE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP
Mailing Address - Street 1:2817 ROCK MERRIT AVE EXECUTIVE MEDICINE
Mailing Address - Street 2:
Mailing Address - City:FORT LIBERTY
Mailing Address - State:NC
Mailing Address - Zip Code:28310-0001
Mailing Address - Country:US
Mailing Address - Phone:910-907-7827
Mailing Address - Fax:
Practice Address - Street 1:WOMACK ARMY MEDICAL CENTER, MCXC-PC-WRC
Practice Address - Street 2:2817 ROCK MERRITT AVE, STOP A
Practice Address - City:FORT LIBERTY
Practice Address - State:NC
Practice Address - Zip Code:28310-5000
Practice Address - Country:US
Practice Address - Phone:910-907-8500
Practice Address - Fax:910-907-8630
Is Sole Proprietor?:No
Enumeration Date:2014-07-16
Last Update Date:2024-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP125791363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily