Provider Demographics
NPI:1063921930
Name:NWADIGO, ROSELINE O
Entity type:Individual
Prefix:
First Name:ROSELINE
Middle Name:O
Last Name:NWADIGO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1705 BEACON BLUFF ST
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27604-5446
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2305 GLASCOCK ST
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27610-1601
Practice Address - Country:US
Practice Address - Phone:984-200-5740
Practice Address - Fax:984-200-5740
Is Sole Proprietor?:No
Enumeration Date:2017-09-23
Last Update Date:2019-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCFCL092234372600000X
NC5011108363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No372600000XNursing Service Related ProvidersAdult Companion
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2305Medicaid