MEDICARE: MR. NICHOLAS LEARY RN

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	163WA2000X	Administrator Registered Nurse	239595	NC

General Provider Information

NPI Number	:	1588357859
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. NICHOLAS LEARY RN

Provider Business Mailing Address
First Line	:	1813 BERRYHILL RD
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28208-5113
Country	:	US
Telephone Number	:	704-644-9164
Fax Number	:

Provider Business Practice Location Address
First Line	:	1813 BERRYHILL RD
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28208-5113
Country	:	US
Telephone Number	:	704-644-9164
Fax Number	:

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

Provider Enumeration Date	:	06/01/2023
Last Update Date	:	06/01/2023

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