MEDICARE: URSULA DOUGLAS FNP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	5011569	NC

General Provider Information

NPI Number	:	1548729189
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	URSULA DOUGLAS FNP

Provider Business Mailing Address
First Line	:	710 E 7TH ST APT 409
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28202-3037
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	8535 CLIFF CAMERON DR STE 116
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28269-5909
Country	:	US
Telephone Number	:	704-971-9191
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/13/2019
Last Update Date	:	03/13/2019

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