Provider Demographics
NPI:1790720829
Name:SOUCY, SALLY RAE (CNM, ARNP)
Entity type:Individual
Prefix:
First Name:SALLY
Middle Name:RAE
Last Name:SOUCY
Suffix:
Gender:F
Credentials:CNM, ARNP
Other - Prefix:
Other - First Name:SALLY
Other - Middle Name:R
Other - Last Name:MCMORRIS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2209 S STERLING ST STE 400
Mailing Address - Street 2:
Mailing Address - City:MORGANTON
Mailing Address - State:NC
Mailing Address - Zip Code:28655-4092
Mailing Address - Country:US
Mailing Address - Phone:828-580-4661
Mailing Address - Fax:828-580-4698
Practice Address - Street 1:1208 HICKORY BLVD SW STE 102
Practice Address - Street 2:
Practice Address - City:LENOIR
Practice Address - State:NC
Practice Address - Zip Code:28645-6461
Practice Address - Country:US
Practice Address - Phone:828-580-4661
Practice Address - Fax:828-580-4698
Is Sole Proprietor?:No
Enumeration Date:2006-06-20
Last Update Date:2022-09-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC625367A00000X, 367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL302018500Medicaid
FLE5987AMedicare ID - Type UnspecifiedMEDICARE
FL302018500Medicaid