Provider Demographics
NPI:1922608686
Name:UMPHLETT, TIMOTHY WAYNE SR (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:MR
First Name:TIMOTHY
Middle Name:WAYNE
Last Name:UMPHLETT
Suffix:SR
Gender:M
Credentials:NURSE PRACTITIONER
Other - Prefix:MR
Other - First Name:TIM
Other - Middle Name:WAYNE
Other - Last Name:UMPHLETT
Other - Suffix:SR
Other - Last Name Type:Professional Name
Other - Credentials:NURSE PRACTITIONER
Mailing Address - Street 1:PO BOX 628
Mailing Address - Street 2:
Mailing Address - City:WINDSOR
Mailing Address - State:NC
Mailing Address - Zip Code:27983-0628
Mailing Address - Country:US
Mailing Address - Phone:252-794-3042
Mailing Address - Fax:252-794-2911
Practice Address - Street 1:104 RHODES AVE
Practice Address - Street 2:
Practice Address - City:WINDSOR
Practice Address - State:NC
Practice Address - Zip Code:27983-9656
Practice Address - Country:US
Practice Address - Phone:252-794-3042
Practice Address - Fax:252-794-2911
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-30
Last Update Date:2020-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5013703363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily