Healthcare Provider Details

I. General information

NPI: 1013387018
Provider Name (Legal Business Name): LAUREN AMANDA LEGGETT AGACNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/02/2015
Last Update Date: 04/11/2022
Certification Date: 04/11/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1918 RANDOLPH RD STE 580
CHARLOTTE NC
28207
US

IV. Provider business mailing address

PO BOX 60447
CHARLOTTE NC
28260-0447
US

V. Phone/Fax

Practice location:
  • Phone: 704-384-9900
  • Fax: 704-384-9919
Mailing address:
  • Phone: 704-384-9900
  • Fax: 704-384-9919

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number5008055
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number5008055
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: