Basic Information
| Provider Information | |||||||||
| NPI: | 1013571561 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | HARRIS | ||||||||
| FirstName: | JOSEPH | ||||||||
| MiddleName: | PATRICK | ||||||||
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| Credential: | RN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 713 S MARSHALL ST | ||||||||
| Address2: | |||||||||
| City: | WINSTON SALEM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 271015808 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3367227266 | ||||||||
| FaxNumber: | 3362010538 | ||||||||
| Practice Location | |||||||||
| Address1: | 104 CAMBRIDGE PLAZA DR | ||||||||
| Address2: | |||||||||
| City: | WINSTON SALEM | ||||||||
| State: | NC | ||||||||
| PostalCode: | 271043556 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3367227266 | ||||||||
| FaxNumber: | 3362010538 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/30/2019 | ||||||||
| LastUpdateDate: | 05/27/2019 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WP0808X | 259677 | NC | N | Nursing Service Providers | Registered Nurse | Psych/Mental Health | 363LP0808X | 5011813 | NC | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 259677 | 01 | RN LICENSE # | OTHER | 5011813 | 01 | NC | NP LICENSE # | OTHER |