Provider Demographics
NPI:1609603299
Name:OVERTON, JEROME ELLIS (RN)
Entity type:Individual
Prefix:
First Name:JEROME
Middle Name:ELLIS
Last Name:OVERTON
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:187 PLANTERS ROW RD
Mailing Address - Street 2:
Mailing Address - City:IRON STATION
Mailing Address - State:NC
Mailing Address - Zip Code:28080-6714
Mailing Address - Country:US
Mailing Address - Phone:704-748-3926
Mailing Address - Fax:
Practice Address - Street 1:200 HAWTHORNE LN
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28204-2515
Practice Address - Country:US
Practice Address - Phone:704-384-4000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-17
Last Update Date:2024-09-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC333863163WC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC0200XNursing Service ProvidersRegistered NurseCritical Care Medicine