Provider Demographics
NPI:1952070781
Name:PURWIN, NICOLE SARA
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:SARA
Last Name:PURWIN
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 1:2116 RAVENGLASS PL APT H
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27612-2911
Mailing Address - Country:US
Mailing Address - Phone:973-452-6222
Mailing Address - Fax:
Practice Address - Street 1:800 W WILLIAMS ST STE 231F
Practice Address - Street 2:
Practice Address - City:APEX
Practice Address - State:NC
Practice Address - Zip Code:27502-5204
Practice Address - Country:US
Practice Address - Phone:919-348-2838
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-07
Last Update Date:2021-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language PathologistGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJW267382948OtherAETNA