Provider Demographics
NPI:1154018703
Name:PREACHER, RODDERRICK (RN)
Entity type:Individual
Prefix:MR
First Name:RODDERRICK
Middle Name:
Last Name:PREACHER
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1914 J N PEASE PL STE 116
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28262-4504
Mailing Address - Country:US
Mailing Address - Phone:980-294-6230
Mailing Address - Fax:980-236-1134
Practice Address - Street 1:1914 J N PEASE PL STE 116
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28262-4504
Practice Address - Country:US
Practice Address - Phone:980-294-6230
Practice Address - Fax:980-236-1134
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-21
Last Update Date:2023-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC283158163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse