Healthcare Provider Details

I. General information

NPI: 1952401416
Provider Name (Legal Business Name): AMY PUCHALSKI
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/25/2006
Last Update Date: 11/08/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 BLYTHE BLVD
CHARLOTTE NC
28203-5812
US

IV. Provider business mailing address

1000 BLYTHE BLVD
CHARLOTTE NC
28203-5812
US

V. Phone/Fax

Practice location:
  • Phone: 704-355-2171
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License NumberMD30864
License Number StateSC
# 2
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number2013-01475
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: