Healthcare Provider Details

I. General information

NPI: 1770024747
Provider Name (Legal Business Name): DARCY RAE PENNETTA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/10/2017
Last Update Date: 03/10/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1016 EUCLID AVE
CHARLOTTE NC
28203-4520
US

IV. Provider business mailing address

9611 BROOKDALE DR SUITE 100-122
CHARLOTTE NC
28215-8719
US

V. Phone/Fax

Practice location:
  • Phone: 704-807-5699
  • Fax: 704-631-4574
Mailing address:
  • Phone: 704-807-5699
  • Fax: 704-631-4574

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: