Healthcare Provider Details

I. General information

NPI: 1033222864
Provider Name (Legal Business Name): AMANDA DALE-SHALL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/16/2006
Last Update Date: 02/12/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 BLYTHE BLVD MEDICAL CENTER PLAZA SUITE 200
CHARLOTTE NC
28203-5866
US

IV. Provider business mailing address

1001 BLYTHE BLVD
CHARLOTTE NC
28203-5866
US

V. Phone/Fax

Practice location:
  • Phone: 704-381-8840
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0201X
TaxonomyPediatric Allergy/Immunology Physician
License Number2007-00714
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: