Basic Information
| Provider Information | |||||||||
| NPI: | 1609216803 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | THEBERGE | ||||||||
| FirstName: | DANIELLE | ||||||||
| MiddleName: | FECK | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | WHNP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | FECK | ||||||||
| OtherFirstName: | DANIELLE | ||||||||
| OtherMiddleName: | GRAHAM | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | WHNP | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 1202 MEDICAL CENTER DR | ||||||||
| Address2: | |||||||||
| City: | WILMINGTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 284017307 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9103413300 | ||||||||
| FaxNumber: | 9108153141 | ||||||||
| Practice Location | |||||||||
| Address1: | 1124 GALLERY PARK LN | ||||||||
| Address2: | |||||||||
| City: | WILMINGTON | ||||||||
| State: | NC | ||||||||
| PostalCode: | 284121142 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9103413300 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/02/2013 | ||||||||
| LastUpdateDate: | 01/13/2021 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 01/13/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WW0101X | 5006300 | NC | N | Nursing Service Providers | Registered Nurse | Women's Health Care, Ambulatory | 163WW0101X | NP0990745 | CO | N | Nursing Service Providers | Registered Nurse | Women's Health Care, Ambulatory | 363LW0102X | 5006300 | NC | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Women's Health | 363L00000X | 5006300 | NC | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.