Provider Demographics
NPI:1790476869
Name:LANDRETH, ANNELISE BARBARA YVONNE (MSN, FNP)
Entity Type:Individual
Prefix:
First Name:ANNELISE
Middle Name:BARBARA YVONNE
Last Name:LANDRETH
Suffix:
Gender:F
Credentials:MSN, FNP
Other - Prefix:
Other - First Name:ANNELISE
Other - Middle Name:
Other - Last Name:ROGERS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 602195
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-2195
Mailing Address - Country:US
Mailing Address - Phone:919-350-0351
Mailing Address - Fax:919-350-7687
Practice Address - Street 1:4530 FAYETTEVILLE RD
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27603-3614
Practice Address - Country:US
Practice Address - Phone:919-235-1930
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-18
Last Update Date:2023-10-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5018604363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1790476869Medicaid