Provider Demographics
NPI:1821580713
Name:MCRAE, NICOLE ANN
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:ANN
Last Name:MCRAE
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 1:2645 MERIDIAN PKWY STE 323
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27713-4232
Mailing Address - Country:US
Mailing Address - Phone:984-227-8902
Mailing Address - Fax:704-921-1022
Practice Address - Street 1:6700 ALBEMARLE RD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28212-3856
Practice Address - Country:US
Practice Address - Phone:704-921-1000
Practice Address - Fax:704-921-1022
Is Sole Proprietor?:No
Enumeration Date:2018-06-05
Last Update Date:2021-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5010593363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1821580713Medicaid