Provider Demographics
NPI:1174869200
Name:HARRELL, JENNIFER HAYNES (FNP-C)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:HAYNES
Last Name:HARRELL
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4366 WAKEMAN DR
Mailing Address - Street 2:
Mailing Address - City:WINSTON SALEM
Mailing Address - State:NC
Mailing Address - Zip Code:27105-3335
Mailing Address - Country:US
Mailing Address - Phone:336-829-8215
Mailing Address - Fax:336-721-6198
Practice Address - Street 1:101 N CHERRY ST FL 2
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27101-4009
Practice Address - Country:US
Practice Address - Phone:336-733-0549
Practice Address - Fax:336-721-6198
Is Sole Proprietor?:No
Enumeration Date:2012-12-18
Last Update Date:2024-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5005798363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily