Provider Demographics
NPI:1306975974
Name:PREVOST, MARY ELLEN (NP)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:ELLEN
Last Name:PREVOST
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1511 WESTOVER TER
Mailing Address - Street 2:SUITE 201
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27408-7128
Mailing Address - Country:US
Mailing Address - Phone:336-373-0611
Mailing Address - Fax:
Practice Address - Street 1:1511 WESTOVER TER
Practice Address - Street 2:SUITE 201
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27408-7128
Practice Address - Country:US
Practice Address - Phone:336-373-0611
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-02
Last Update Date:2022-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC153275163W00000X
NC0050-00029363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCZF0000184Medicaid