Healthcare Provider Details

I. General information

NPI: 1831617455
Provider Name (Legal Business Name): TSHA EDITH PUNGU
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/04/2017
Last Update Date: 09/04/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2905 FREEDOM DR
CHARLOTTE NC
28208
US

IV. Provider business mailing address

5808 HUNTING RIDGE LANE APT A
CHARLOTTE NC
28212
US

V. Phone/Fax

Practice location:
  • Phone: 704-394-3033
  • Fax:
Mailing address:
  • Phone: 704-281-8806
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberF07171238
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: