Healthcare Provider Details

I. General information

NPI: 1699700484
Provider Name (Legal Business Name): MARY C HEAD NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/11/2006
Last Update Date: 09/26/2025
Certification Date: 09/26/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

457 N WENDOVER RD
CHARLOTTE NC
28211-1064
US

IV. Provider business mailing address

457 N WENDOVER RD
CHARLOTTE NC
28211-1064
US

V. Phone/Fax

Practice location:
  • Phone: 704-817-3808
  • Fax: 877-471-2522
Mailing address:
  • Phone: 704-817-3808
  • Fax: 877-471-2522

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number900417
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number900417
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number0009-00417
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: