Provider Demographics
NPI: | 1790720829 |
---|---|
Name: | SOUCY, SALLY RAE (CNM, ARNP) |
Entity Type: | Individual |
Prefix: | |
First Name: | SALLY |
Middle Name: | RAE |
Last Name: | SOUCY |
Suffix: | |
Gender: | F |
Credentials: | CNM, ARNP |
Other - Prefix: | |
Other - First Name: | SALLY |
Other - Middle Name: | R |
Other - Last Name: | MCMORRIS |
Other - Suffix: | |
Other - Last Name Type: | Former Name |
Other - Credentials: | |
Mailing Address - Street 1: | 2209 S STERLING ST STE 400 |
Mailing Address - Street 2: | |
Mailing Address - City: | MORGANTON |
Mailing Address - State: | NC |
Mailing Address - Zip Code: | 28655-4092 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 828-580-4661 |
Mailing Address - Fax: | 828-580-4698 |
Practice Address - Street 1: | 1208 HICKORY BLVD SW STE 102 |
Practice Address - Street 2: | |
Practice Address - City: | LENOIR |
Practice Address - State: | NC |
Practice Address - Zip Code: | 28645-6461 |
Practice Address - Country: | US |
Practice Address - Phone: | 828-580-4661 |
Practice Address - Fax: | 828-580-4698 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2006-06-20 |
Last Update Date: | 2022-09-02 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
NC | 625 | 367A00000X, 367A00000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 367A00000X | Physician Assistants & Advanced Practice Nursing Providers | Advanced Practice Midwife |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
FL | 302018500 | Medicaid | |
FL | E5987A | Medicare ID - Type Unspecified | MEDICARE |
FL | 302018500 | Medicaid |