Healthcare Provider Details

I. General information

NPI: 1700018728
Provider Name (Legal Business Name): NICOLE BLOHM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/10/2009
Last Update Date: 02/26/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5727 PROSPERITY CROSSING DR SUITE 2200
CHARLOTTE NC
28269-2206
US

IV. Provider business mailing address

5727 PROSPERITY CROSSING DR SUITE 2200
CHARLOTTE NC
28269-2206
US

V. Phone/Fax

Practice location:
  • Phone: 704-863-9830
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number0010-01566
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: