Healthcare Provider Details

I. General information

NPI: 1801893839
Provider Name (Legal Business Name): JENNIFER MANTER LANCASTER CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/05/2005
Last Update Date: 12/30/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10628 PARK RD CAROLINAS MEDICAL CENTER-PINEVILLE
CHARLOTTE NC
28210-8407
US

IV. Provider business mailing address

6633 SILVER FOX RD
CHARLOTTE NC
28270-0683
US

V. Phone/Fax

Practice location:
  • Phone: 704-667-1000
  • Fax: 704-667-0409
Mailing address:
  • Phone: 704-443-5237
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN-254444
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberNA07357
License Number StateOH
# 3
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number80491
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: