Provider Demographics
NPI:1962447342
Name:HAWTHORNE, ANITA
Entity Type:Individual
Prefix:
First Name:ANITA
Middle Name:
Last Name:HAWTHORNE
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 1:971 SALISBURY RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27127-3709
Mailing Address - Country:US
Mailing Address - Phone:800-380-1947
Mailing Address - Fax:336-777-0624
Practice Address - Street 1:971 SALISBURY RIDGE RD
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27127-3709
Practice Address - Country:US
Practice Address - Phone:800-380-1947
Practice Address - Fax:336-777-0624
Is Sole Proprietor?:No
Enumeration Date:2006-06-18
Last Update Date:2007-10-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC1565146L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes146L00000XEmergency Medical Service ProvidersEmergency Medical Technician, Paramedic
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC43558OtherPARTNERS MEDICARE
NC3406883Medicaid
NC0720ROtherBCBS
NC2783082Medicare ID - Type Unspecified