Healthcare Provider Details

I. General information

NPI: 1972814754
Provider Name (Legal Business Name): DIEDRA PATTON HUFFMAN FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/28/2010
Last Update Date: 07/15/2024
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14214 BALLANTYNE LAKE RD STE 100
CHARLOTTE NC
28277-3372
US

IV. Provider business mailing address

PO BOX 19305
CHARLOTTE NC
28219-9305
US

V. Phone/Fax

Practice location:
  • Phone: 704-667-2650
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number5004763
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: