Healthcare Provider Details

I. General information

NPI: 1043490113
Provider Name (Legal Business Name): JENNIFER LAIACONA CAICEDO M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/06/2007
Last Update Date: 07/21/2022
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8045 PROVIDENCE RD STE 300
CHARLOTTE NC
28277
US

IV. Provider business mailing address

8045 PROVIDENCE RD STE 300
CHARLOTTE NC
28277-8915
US

V. Phone/Fax

Practice location:
  • Phone: 704-341-9600
  • Fax: 855-380-3762
Mailing address:
  • Phone: 704-341-9600
  • Fax: 855-380-3762

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number2009-00855
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code207K00000X
TaxonomyAllergy & Immunology Physician
License Number2009-00855
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: