Provider Demographics
NPI:1184143489
Name:EXTENSION TRAINING OF NC, LLC
Entity type:Organization
Organization Name:EXTENSION TRAINING OF NC, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:CHRISTINA
Authorized Official - Middle Name:LANETTE
Authorized Official - Last Name:STEVENSON
Authorized Official - Suffix:
Authorized Official - Credentials:FNP, ANP, RN-BC
Authorized Official - Phone:919-592-3608
Mailing Address - Street 1:1120 LOMBAR ST
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27610-6499
Mailing Address - Country:US
Mailing Address - Phone:704-806-2156
Mailing Address - Fax:
Practice Address - Street 1:700 MORROW AVE
Practice Address - Street 2:
Practice Address - City:PINEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28134-6528
Practice Address - Country:US
Practice Address - Phone:919-592-3608
Practice Address - Fax:919-835-9613
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-09-18
Last Update Date:2017-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC254418261QM0850X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0850XAmbulatory Health Care FacilitiesClinic/CenterAdult Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5007400OtherNURSE PRACTITIONER