Provider Demographics
NPI:1922708858
Name:AVERY, ABIGAIL LOUISE
Entity Type:Individual
Prefix:
First Name:ABIGAIL
Middle Name:LOUISE
Last Name:AVERY
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 1:2198 N WOODLAND RD
Mailing Address - Street 2:
Mailing Address - City:HENDERSON
Mailing Address - State:NC
Mailing Address - Zip Code:27536-3824
Mailing Address - Country:US
Mailing Address - Phone:804-894-2954
Mailing Address - Fax:
Practice Address - Street 1:511 RUIN CREEK RD STE 101
Practice Address - Street 2:
Practice Address - City:HENDERSON
Practice Address - State:NC
Practice Address - Zip Code:27536-5919
Practice Address - Country:US
Practice Address - Phone:252-436-0440
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-08
Last Update Date:2023-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-13477363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant