Healthcare Provider Details

I. General information

NPI: 1023956471
Provider Name (Legal Business Name): MRS. IVEY NOELLE WEIMER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: IVEY NOELLE WAGNER

II. Dates (important events)

Enumeration Date: 03/24/2026
Last Update Date: 06/03/2026
Certification Date: 06/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

225 BALDWIN AVE
CHARLOTTE NC
28204-3109
US

IV. Provider business mailing address

525 VINE ST STE 530
WINSTON SALEM NC
27101-4155
US

V. Phone/Fax

Practice location:
  • Phone: 704-376-1605
  • Fax:
Mailing address:
  • Phone: 336-716-4356
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: