Provider Demographics
NPI:1992762777
Name:CENTOFANTE, NANCY L (MD)
Entity type:Individual
Prefix:DR
First Name:NANCY
Middle Name:L
Last Name:CENTOFANTE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:NANCY
Other - Middle Name:L
Other - Last Name:CLEMONS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:1706 MEDICAL PARK DR W
Mailing Address - Street 2:
Mailing Address - City:WILSON
Mailing Address - State:NC
Mailing Address - Zip Code:27893-2705
Mailing Address - Country:US
Mailing Address - Phone:410-708-1036
Mailing Address - Fax:
Practice Address - Street 1:1706 MEDICAL PARK DR W
Practice Address - Street 2:
Practice Address - City:WILSON
Practice Address - State:NC
Practice Address - Zip Code:27893-2705
Practice Address - Country:US
Practice Address - Phone:252-243-3223
Practice Address - Fax:252-243-3668
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-27
Last Update Date:2020-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC198493207L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207L00000XAllopathic & Osteopathic PhysiciansAnesthesiology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD68639503OtherBCBS MD
MDF2320002OtherBCBS DC NCA
MD397641600Medicaid
MD68639503OtherBCBS MD
MDF2320002OtherBCBS DC NCA