Healthcare Provider Details

I. General information

NPI: 1992457550
Provider Name (Legal Business Name): QUEEN CITY LABORATORY SERVICES, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/24/2022
Last Update Date: 02/22/2022
Certification Date: 02/22/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10150 MALLARD CREEK RD STE 104
CHARLOTTE NC
28262-4567
US

IV. Provider business mailing address

10150 MALLARD CREEK RD STE 104
CHARLOTTE NC
28262-4567
US

V. Phone/Fax

Practice location:
  • Phone: 240-468-9428
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207RI0001X
TaxonomyClinical & Laboratory Immunology (Internal Medicine) Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code246QL0900X
TaxonomyLaboratory Management Specialist/Technologist
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code246QL0901X
TaxonomyDiplomate Laboratory Management Specialist/Technologist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code246RM2200X
TaxonomyMedical Laboratory Technician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code247ZC0005X
TaxonomyClinical Laboratory Director (Non-physician)
License Number
License Number State
# 6
Primary TaxonomyY
Taxonomy Code207ZP0105X
TaxonomyClinical Pathology/Laboratory Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: LEENA DREW
Title or Position: OWNER
Credential: DNP, FNP-C
Phone: 240-468-9428