Provider Demographics
NPI:1417693938
Name:FAYETTEVILLE FINGERPRINTING & DIAGNOSTICS, LLC
Entity type:Organization
Organization Name:FAYETTEVILLE FINGERPRINTING & DIAGNOSTICS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:SHAKIA
Authorized Official - Middle Name:LEANN
Authorized Official - Last Name:NELSON
Authorized Official - Suffix:
Authorized Official - Credentials:LABORATORY DIRECTOR
Authorized Official - Phone:910-218-0015
Mailing Address - Street 1:1830 OWEN DR STE 202-2
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28304-1611
Mailing Address - Country:US
Mailing Address - Phone:910-218-0015
Mailing Address - Fax:910-500-3999
Practice Address - Street 1:1830 OWEN DR STE 202-2
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28304-1611
Practice Address - Country:US
Practice Address - Phone:912-432-4116
Practice Address - Fax:910-500-3999
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-05-08
Last Update Date:2022-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory