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SHEPS CENTER DATA REQUEST FORM: NC Health Professions Data
Other Statistical Data

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Requester's Name:
Business Name:
Address:
City, State & ZIP:
Telephone Number:
Fax Number:
Email Address:

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SELECTION CRITERIA (check all that apply):
Profession:
Chiropractors
Dental Hygienists
Dentists
Licensed Practical Nurses
Nurse Practitioners
Optometrists
Pharmacists
Physical Therapists
Physical Therapy Assistants
Physicians: Medical Doctors
Physicians: Doctors of Osteopathy
Physicians: Residents-in-training
Physician Assistants
Podiatrists
Psychologists
Psychological Associates
Registered Nurses

Activity Status:
Active
Inactive

Area Selection:
In-state
Out-of-state
Specific counties:
Other (please specify)

Federal Provider Indicator (for physician requests only):
Non-Federal
Federal (physicians in the armed services, US Public Health Service, Indian Health Service, or the Department of Veterans Affairs)

Description of Request:
List the details of your request in the box below:


How did you hear about the NC Health Professions Web Page?


Do you have any questions? Suggestions? Comments? Please enter them below.


NOTICE: Simple data requests for statistical information can often be provided free of charge. If your request requires special programming, you will be contacted regarding an estimated charge for your request.

NOTICE: Data are provided by the respective licensing boards as of October each year and compiled by the Sheps Center. Address changes are made only at the time of the annual update. Contact the Sheps Center Data Coordinator at (919)966-7112 for more detailed information regarding the Sheps Center files.

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Last update: 7/97