Healthcare Provider Details

I. General information

NPI: 1346515681
Provider Name (Legal Business Name): JENNIFER CASTRO-PRUETT R.N.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/20/2012
Last Update Date: 03/20/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3609 JOEL TURNER DR
CHARLOTTE NC
28216-7635
US

IV. Provider business mailing address

3609 JOEL TURNER DR
CHARLOTTE NC
28216-7635
US

V. Phone/Fax

Practice location:
  • Phone: 904-226-3362
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number245250
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number9316225
License Number StateFL
# 3
Primary TaxonomyN
Taxonomy Code163WH0200X
TaxonomyHome Health Registered Nurse
License Number245250
License Number StateNC
# 4
Primary TaxonomyY
Taxonomy Code163WP0200X
TaxonomyPediatric Registered Nurse
License Number245250
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: