Healthcare Provider Details

I. General information

NPI: 1063041432
Provider Name (Legal Business Name): ROSE JACQUELINE MCNULTY MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/07/2020
Last Update Date: 08/13/2026
Certification Date: 08/13/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3623 LATROBE DR STE 216
CHARLOTTE NC
28211-2117
US

IV. Provider business mailing address

PO BOX 221249
CHARLOTTE NC
28222-1249
US

V. Phone/Fax

Practice location:
  • Phone: 704-332-1291
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number2024-01624
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: