Healthcare Provider Details

I. General information

NPI: 1689454241
Provider Name (Legal Business Name): ROSA MIRNA MEDINA FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/02/2023
Last Update Date: 11/13/2025
Certification Date: 11/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8401 MEDICAL PLAZA DR STE 300
CHARLOTTE NC
28262-8702
US

IV. Provider business mailing address

8401 MEDICAL PLAZA DR STE 300
CHARLOTTE NC
28262-8702
US

V. Phone/Fax

Practice location:
  • Phone: 704-316-6561
  • Fax:
Mailing address:
  • Phone: 704-316-6561
  • Fax: 704-384-1974

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number331759
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number5021474
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: