Provider Demographics
NPI:1821492315
Name:SALLY, DEDRA (CNM)
Entity Type:Individual
Prefix:
First Name:DEDRA
Middle Name:
Last Name:SALLY
Suffix:
Gender:F
Credentials:CNM
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Mailing Address - Street 1:10010 FALLS OF NEUSE RD
Mailing Address - Street 2:SUITE 205
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27614-8494
Mailing Address - Country:US
Mailing Address - Phone:919-350-1380
Mailing Address - Fax:919-556-0124
Practice Address - Street 1:10010 FALLS OF NEUSE RD
Practice Address - Street 2:SUITE 205
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27614-8494
Practice Address - Country:US
Practice Address - Phone:919-350-1380
Practice Address - Fax:919-350-7918
Is Sole Proprietor?:No
Enumeration Date:2014-10-13
Last Update Date:2019-06-21
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
NJ25ME00056001367A00000X
NJ25ME00056000367A00000X
NC583367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1821492315Medicaid