Healthcare Provider Details

I. General information

NPI: 1326274713
Provider Name (Legal Business Name): DEBRA ANNE NICKERSON NNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/31/2009
Last Update Date: 11/28/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 BLYTHE BLVD SUITE 200
CHARLOTTE NC
28203-5866
US

IV. Provider business mailing address

PO BOX 601372 1001 BLYTHE BLVD., SUITE 200
CHARLOTTE NC
28260-1372
US

V. Phone/Fax

Practice location:
  • Phone: 704-381-8840
  • Fax: 704-381-8848
Mailing address:
  • Phone: 704-381-8840
  • Fax: 704-381-8848

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LN0005X
TaxonomyCritical Care Neonatal Nurse Practitioner
License Number185859
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: