NPIMap

Organization Active NPI

Lifesource of North Carolina

  • Nurse Practitioner
  • Holland, OH
National Provider Identifier
1710620117
Registry record updated Apr 10, 2024
On this page

Key facts

NPPES NPI Registry
Primary specialty
Nurse PractitionerTaxonomy code 363L00000X
Legal business name
LIFESOURCE OF NORTH CAROLINA
Practice address
1525 Eber Rd
Holland, OH 43528-9616
Phone
(910) 742-9243
NPI assigned
Apr 14, 2022
Organization subpart
No

NPPES NPI Registry

Updated by the provider on Apr 10, 2024

Registry information is reported by the provider to CMS and is not verified. About this source

Authorized official

Name
Amanda Seymour
Title
Credentialing Specialist
Phone
(910) 794-4521

Specialties & licenses 4

Specialty (taxonomy)CodeLicenseStatePrimary
Psychiatry PhysicianGroup: 193200000X MULTI-SPECIALTY GROUP 2084P0800X
Physician AssistantGroup: 193200000X MULTI-SPECIALTY GROUP 363A00000X
Nurse PractitionerGroup: 193200000X MULTI-SPECIALTY GROUP 363L00000X Primary
Psychiatric/Mental Health Nurse PractitionerGroup: 193200000X MULTI-SPECIALTY GROUP 363LP0808X

Addresses

Primary practice location

1525 Eber Rd
Holland, OH 43528-9616

Mailing address

PO Box 538622
Atlanta, GA 30353-8622
Phone (910) 742-9243

National Provider Directory

National Provider Directory
Tax ID family
Lifesource of Georgia8 organizations share this tax ID, including this one

Other organizations with this tax ID 7

Organizations that report the same tax identification number in the National Provider Directory.

NPI Registry JSON

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1649894400000",
    "enumeration_type": "NPI-2",
    "last_updated_epoch": "1712707200000",
    "number": "1710620117",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "PO BOX 538622",
            "city": "ATLANTA",
            "state": "GA",
            "postal_code": "303538622",
            "telephone_number": "910-742-9243",
            "fax_number": "888-746-1787"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "1525 EBER RD",
            "city": "HOLLAND",
            "state": "OH",
            "postal_code": "435289616",
            "telephone_number": "910-742-9243"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "organization_name": "LIFESOURCE OF NORTH CAROLINA",
        "organizational_subpart": "NO",
        "enumeration_date": "2022-04-14",
        "last_updated": "2024-04-10",
        "certification_date": "2024-04-10",
        "status": "A",
        "authorized_official_last_name": "SEYMOUR",
        "authorized_official_first_name": "AMANDA",
        "authorized_official_title_or_position": "CREDENTIALING SPECIALIST",
        "authorized_official_telephone_number": "910-794-4521"
    },
    "taxonomies": [
        {
            "code": "2084P0800X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Psychiatry & Neurology, Psychiatry",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "363A00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Physician Assistant",
            "state": null,
            "license": null,
            "primary": false
        },
        {
            "code": "363L00000X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Nurse Practitioner",
            "state": null,
            "license": null,
            "primary": true
        },
        {
            "code": "363LP0808X",
            "taxonomy_group": "193200000X MULTI-SPECIALTY GROUP",
            "desc": "Nurse Practitioner, Psychiatric/Mental Health",
            "state": null,
            "license": null,
            "primary": false
        }
    ],
    "identifiers": [],
    "endpoints": [],
    "other_names": []
}

Other providers in Holland, OH

Sources for this page

  • NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Apr 10, 2024; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
  • National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.