Healthcare Provider Details

I. General information

NPI: 1194203620
Provider Name (Legal Business Name): ERICA DIANE KLOSE NNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/06/2018
Last Update Date: 08/06/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 HAWTHORNE LN
CHARLOTTE NC
28204-2515
US

IV. Provider business mailing address

423 MATFIELD CT
MONROE NC
28110-8123
US

V. Phone/Fax

Practice location:
  • Phone: 704-384-4944
  • Fax:
Mailing address:
  • Phone: 704-502-7660
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LN0005X
TaxonomyCritical Care Neonatal Nurse Practitioner
License Number5010808
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: