Healthcare Provider Details

I. General information

NPI: 1265438089
Provider Name (Legal Business Name): EVA MAE STASSEN FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2005
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3500 MOUNT HOLLY HUNTERSVILLE RD STE 200
CHARLOTTE NC
28216-8644
US

IV. Provider business mailing address

11216 STONY PATH DR
CHARLOTTE NC
28214-9287
US

V. Phone/Fax

Practice location:
  • Phone: 704-399-7800
  • Fax: 704-399-7717
Mailing address:
  • Phone: 704-391-2866
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number201604
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: