Provider Demographics
NPI:1790324457
Name:WALL, CAVASSINE ZATANE
Entity Type:Individual
Prefix:
First Name:CAVASSINE
Middle Name:ZATANE
Last Name:WALL
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 1:112 PEACHTREE CT
Mailing Address - Street 2:
Mailing Address - City:HAMLET
Mailing Address - State:NC
Mailing Address - Zip Code:28345-8804
Mailing Address - Country:US
Mailing Address - Phone:910-206-5145
Mailing Address - Fax:
Practice Address - Street 1:315A S LONG DR
Practice Address - Street 2:
Practice Address - City:ROCKINGHAM
Practice Address - State:NC
Practice Address - Zip Code:28379-3991
Practice Address - Country:US
Practice Address - Phone:910-206-5145
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-29
Last Update Date:2019-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health