Healthcare Provider Details

I. General information

NPI: 1811578040
Provider Name (Legal Business Name): GRETHA NGOMA BANDA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/19/2021
Last Update Date: 10/21/2024
Certification Date: 10/21/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6133 THE PLZ
CHARLOTTE NC
28215-2401
US

IV. Provider business mailing address

200 E 2ND AVE
GASTONIA NC
28052-4358
US

V. Phone/Fax

Practice location:
  • Phone: 704-887-3840
  • Fax:
Mailing address:
  • Phone: 704-874-1907
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2020129050
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: