Healthcare Provider Details

I. General information

NPI: 1851585384
Provider Name (Legal Business Name): JENNIFER V NGUYEN MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/28/2007
Last Update Date: 12/14/2022
Certification Date: 12/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8936 BLAKENEY PROFESSIONAL DR
CHARLOTTE NC
28277-6660
US

IV. Provider business mailing address

1450 PROFESSIONAL PARK DR STE 150
WINSTON SALEM NC
27103-1307
US

V. Phone/Fax

Practice location:
  • Phone: 704-943-3714
  • Fax:
Mailing address:
  • Phone: 336-724-2434
  • Fax: 336-607-8061

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberMD443696
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License NumberD82013
License Number StateMD
# 3
Primary TaxonomyN
Taxonomy Code207ND0900X
TaxonomyDermatopathology Physician
License NumberMD443696
License Number StatePA
# 4
Primary TaxonomyN
Taxonomy Code207ND0900X
TaxonomyDermatopathology Physician
License NumberD0082013
License Number StateMD
# 5
Primary TaxonomyY
Taxonomy Code207ND0900X
TaxonomyDermatopathology Physician
License Number2022-02326
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: