MEDICARE: JACQUELINE FARRELL PLOSZAK FNP-BC

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	5007369	NC
2	363L00000X	Nurse Practitioner	5007369	NC

General Provider Information

NPI Number	:	1649678624
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JACQUELINE FARRELL PLOSZAK FNP-BC

Provider Business Mailing Address
First Line	:	PO BOX 601843
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28260-1843
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4815 BEREWICK TOWN CENTER DR STE C&D
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28278-6733
Country	:	US
Telephone Number	:	980-337-4652
Fax Number	:	980-337-4653

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

Provider Enumeration Date	:	12/08/2014
Last Update Date	:	07/14/2021

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