Provider Demographics
NPI:1942228333
Name:SUMMERLIN, JULIENNE ANNETTE (PA)
Entity type:Individual
Prefix:MS
First Name:JULIENNE
Middle Name:ANNETTE
Last Name:SUMMERLIN
Suffix:
Gender:F
Credentials:PA
Other - Prefix:MRS
Other - First Name:JULIENNE
Other - Middle Name:SUMMERLIN
Other - Last Name:CONNOR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA
Mailing Address - Street 1:621 S MAIN ST STE 100
Mailing Address - Street 2:
Mailing Address - City:REIDSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:27320-5034
Mailing Address - Country:US
Mailing Address - Phone:336-342-6880
Mailing Address - Fax:
Practice Address - Street 1:621 S MAIN ST STE 100
Practice Address - Street 2:
Practice Address - City:REIDSVILLE
Practice Address - State:NC
Practice Address - Zip Code:27320-5034
Practice Address - Country:US
Practice Address - Phone:336-342-6880
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-17
Last Update Date:2022-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC101517363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
R18946Medicare UPIN
NC2745976BMedicare PIN
NC2745976EMedicare PIN
NC2745976DMedicare PIN
NC2745976AMedicare PIN