Healthcare Provider Details

I. General information

NPI: 1053902270
Provider Name (Legal Business Name): JASMINE MARYBELLE ZUCHOWSKI
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/30/2021
Last Update Date: 11/28/2022
Certification Date: 11/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7940 WILLIAMS POND LN STE 100
CHARLOTTE NC
28277-8410
US

IV. Provider business mailing address

1901 RANDOLPH RD
CHARLOTTE NC
28207-1101
US

V. Phone/Fax

Practice location:
  • Phone: 704-752-7779
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number301676
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number5017105
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: