Basic Information
| Provider Information | |||||||||
| NPI: | 1225325228 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | FREAS | ||||||||
| FirstName: | SALLY | ||||||||
| MiddleName: | C | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | RN, CDE | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 2511 DELANEY AVE | ||||||||
| Address2: | ATTN: CREDENTIALING | ||||||||
| City: | WILMINGTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 284036003 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9107729202 | ||||||||
| FaxNumber: | 8663458963 | ||||||||
| Practice Location | |||||||||
| Address1: | 1500 PHYSICIANS DR | ||||||||
| Address2: | |||||||||
| City: | WILMINGTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 284017356 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9103413300 | ||||||||
| FaxNumber: | 9102518824 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/29/2011 | ||||||||
| LastUpdateDate: | 05/01/2014 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 85144 | NC | N | Nursing Service Providers | Registered Nurse | 163WD0400X | 0882-5146 | NC | Y | Nursing Service Providers | Registered Nurse | Diabetes Educator |
No ID Information.