Provider Demographics
NPI:1902394067
Name:DESRONVIL, THEODORA (FNP-BC)
Entity Type:Individual
Prefix:
First Name:THEODORA
Middle Name:
Last Name:DESRONVIL
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2723
Mailing Address - Street 2:
Mailing Address - City:ROCKY MOUNT
Mailing Address - State:NC
Mailing Address - Zip Code:27802-2723
Mailing Address - Country:US
Mailing Address - Phone:252-212-3486
Mailing Address - Fax:252-212-3497
Practice Address - Street 1:300 N GRACE ST
Practice Address - Street 2:
Practice Address - City:ROCKY MOUNT
Practice Address - State:NC
Practice Address - Zip Code:27804-5345
Practice Address - Country:US
Practice Address - Phone:252-210-9856
Practice Address - Fax:252-822-5065
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-24
Last Update Date:2020-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC303827163W00000X
NC5010560363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse