Provider Demographics
NPI:1053983098
Name:ABRAHAM, AJITH (PMHNP)
Entity type:Individual
Prefix:
First Name:AJITH
Middle Name:
Last Name:ABRAHAM
Suffix:
Gender:M
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4819 EMPEROR BLVD STE 400
Mailing Address - Street 2:
Mailing Address - City:DURHAM
Mailing Address - State:NC
Mailing Address - Zip Code:27703-5420
Mailing Address - Country:US
Mailing Address - Phone:919-646-6563
Mailing Address - Fax:919-551-7592
Practice Address - Street 1:4819 EMPEROR BLVD STE 400
Practice Address - Street 2:
Practice Address - City:DURHAM
Practice Address - State:NC
Practice Address - Zip Code:27703-5420
Practice Address - Country:US
Practice Address - Phone:919-646-6563
Practice Address - Fax:919-551-7592
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-10
Last Update Date:2024-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024182168363LP0808X
NC284170163W00000X
NC5016227363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse