Healthcare Provider Details

I. General information

NPI: 1053940551
Provider Name (Legal Business Name): STEPHANIE WALTERS WOOD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/06/2020
Last Update Date: 11/06/2025
Certification Date: 11/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 HAWTHORNE LN
CHARLOTTE NC
28204-2515
US

IV. Provider business mailing address

200 HAWTHORNE LN
CHARLOTTE NC
28204-2515
US

V. Phone/Fax

Practice location:
  • Phone: 704-384-4000
  • Fax:
Mailing address:
  • Phone: 704-747-4713
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WN0002X
TaxonomyNeonatal Intensive Care Registered Nurse
License Number279311
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number5015276
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: