Provider Demographics
NPI:1992931216
Name:AVERILL, NANCY DEE (MA, CC-SLP)
Entity type:Individual
Prefix:
First Name:NANCY
Middle Name:DEE
Last Name:AVERILL
Suffix:
Gender:F
Credentials:MA, CC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12211 MEETINGHOUSE DR
Mailing Address - Street 2:
Mailing Address - City:CORNELIUS
Mailing Address - State:NC
Mailing Address - Zip Code:28031-4559
Mailing Address - Country:US
Mailing Address - Phone:660-216-9859
Mailing Address - Fax:
Practice Address - Street 1:20 WESTWOOD MEDICAL PARK
Practice Address - Street 2:
Practice Address - City:BLUEFIELD
Practice Address - State:VA
Practice Address - Zip Code:24605-2003
Practice Address - Country:US
Practice Address - Phone:276-322-5439
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-06-01
Last Update Date:2019-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2005014671235Z00000X
VA2202009066235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO1992931216Medicaid
MO1992931216Medicaid
MOMA1813007Medicare PIN