Provider Demographics
NPI:1740061886
Name:PRODIGY HEALTH AND WELLNESS PLLC
Entity type:Organization
Organization Name:PRODIGY HEALTH AND WELLNESS PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:NURSE PRACTITIONER
Authorized Official - Prefix:
Authorized Official - First Name:LISA
Authorized Official - Middle Name:P
Authorized Official - Last Name:BLEVINS
Authorized Official - Suffix:
Authorized Official - Credentials:DNP
Authorized Official - Phone:919-793-6483
Mailing Address - Street 1:PO BOX 376
Mailing Address - Street 2:
Mailing Address - City:KNIGHTDALE
Mailing Address - State:NC
Mailing Address - Zip Code:27545-0376
Mailing Address - Country:US
Mailing Address - Phone:919-793-6483
Mailing Address - Fax:
Practice Address - Street 1:4000 WAKE FOREST RD
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27609-6879
Practice Address - Country:US
Practice Address - Phone:919-793-6483
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-10-12
Last Update Date:2023-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary CareGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5003510OtherFAMILY MEDICINE