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Organization
PROVIDENCE PEDIATRIC FUNCTIONAL MEDICINE, PLLC
Active
Organization
PROVIDENCE PEDIATRIC FUNCTIONAL MEDICINE, PLLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
NICOLE ANDERSON CPNP-PC (OWNER/AUTHORIZED OFFICIAN)
(743) 224-7137
Entity
Organization
Contact information
Practice address
610 N FAYETTEVILLE ST STE 102, ASHEBORO, NC 27203-4671
(336) 233-7882
Mailing address
610 N FAYETTEVILLE ST STE 102, ASHEBORO, NC 27203-4671
(743) 224-7137
(336) 290-5084
Taxonomy
Speciality
Code
Description
License number
State
261QP2300X
Primary Care Clinic/Center
Primary
—
NULL
363LP0200X
Pediatric Nurse Practitioner
—
NULL
363LP0200X
Pediatric Nurse Practitioner
—
—
Other
Enumeration date
06/03/2026
Last updated
09/18/2026
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