Provider Demographics
NPI:1851599831
Name:MERRITT, MINDY LEE NACE (MD)
Entity Type:Individual
Prefix:
First Name:MINDY
Middle Name:LEE NACE
Last Name:MERRITT
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:MINDY
Other - Middle Name:LEE
Other - Last Name:NACE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:3714 GUARDIAN AVE
Mailing Address - Street 2:SUITE E
Mailing Address - City:MOREHEAD CITY
Mailing Address - State:NC
Mailing Address - Zip Code:28557-2974
Mailing Address - Country:US
Mailing Address - Phone:252-247-2101
Mailing Address - Fax:252-247-4675
Practice Address - Street 1:3714 GUARDIAN AVE
Practice Address - Street 2:SUITE E
Practice Address - City:MOREHEAD CITY
Practice Address - State:NC
Practice Address - Zip Code:28557-2974
Practice Address - Country:US
Practice Address - Phone:252-247-2101
Practice Address - Fax:252-247-4675
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-11
Last Update Date:2014-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC141282208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1714POtherBLUE CROSS BLUE SHIELD
NC5920642Medicaid
NCP01312592OtherRR MEDICARE
NC5920642Medicaid