Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207PP0204X | Pediatric Emergency Physician | F10200006 | NC |
Y | 363L00000X | Nurse Practitioner | 5014106 | NC |
NPI | 1306438304 |
---|---|
Provider Name | Stacie Smith Cockerham |
First Address | Winston Salem, NC 27157-0001 |
Second Address | Winston Salem, NC 27157-0001 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 10/02/2021 |
Last Update Date | 07/05/2021 |