Provider Demographics
NPI:1356881528
Name:ABLAN, JOHN MICHAEL
Entity type:Individual
Prefix:
First Name:JOHN MICHAEL
Middle Name:
Last Name:ABLAN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 BITTERWOOD PL
Mailing Address - Street 2:
Mailing Address - City:GOLDSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27530-0805
Mailing Address - Country:US
Mailing Address - Phone:919-273-5578
Mailing Address - Fax:
Practice Address - Street 1:11200 GOVERNOR MANLY WAY
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27614-8599
Practice Address - Country:US
Practice Address - Phone:919-273-5578
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-07
Last Update Date:2017-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCLAT-2623405300000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes405300000XOther Service ProvidersPrevention Professional