Healthcare Provider Details

I. General information

NPI: 1962093195
Provider Name (Legal Business Name): AMY ZICKEFOOSE KUPSCO FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/30/2021
Last Update Date: 03/27/2025
Certification Date: 03/27/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3158 FREEDOM DR STE 3101
CHARLOTTE NC
28208-0014
US

IV. Provider business mailing address

PO BOX 37938
CHARLOTTE NC
28237-7938
US

V. Phone/Fax

Practice location:
  • Phone: 704-348-2992
  • Fax:
Mailing address:
  • Phone: 704-332-0396
  • Fax: 704-971-0035

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberF01211463
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: