Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207QA0401X | Family Doctor - Addiction Medicine | 2005-01289 | NC |
N | 208000000X | Pediatrician | 151877 | MA |
Y | 208000000X | Pediatrician | 2005-01289 | NC |
NPI | 1356449144 |
---|---|
Provider Name | Immacula Saint-Louis |
First Address | Wilson, NC 27893-4105 |
Second Address | Wilson, NC 27893-4105 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 20/09/2006 |
Last Update Date | 30/10/2017 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
3196209 | (05) | MA |
H00273 | (02) | MA |