Provider Demographics
NPI:1427356153
Name:PRIDDY-SOUTHERN, JOAN (NP)
Entity type:Individual
Prefix:
First Name:JOAN
Middle Name:
Last Name:PRIDDY-SOUTHERN
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 1:145 KIMEL PARK DR
Mailing Address - Street 2:SUITE 330
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27103-6984
Mailing Address - Country:US
Mailing Address - Phone:336-765-6181
Mailing Address - Fax:336-714-6481
Practice Address - Street 1:145 KIMEL PARK DR
Practice Address - Street 2:SUITE 330
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-6984
Practice Address - Country:US
Practice Address - Phone:336-765-6181
Practice Address - Fax:336-714-6481
Is Sole Proprietor?:No
Enumeration Date:2011-03-04
Last Update Date:2020-09-09
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NC83415363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7004906Medicaid
NC259262Medicare PIN