Healthcare Provider Details

I. General information

NPI: 1821816034
Provider Name (Legal Business Name): SOPHIA LYNN YENTZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/27/2024
Last Update Date: 10/31/2024
Certification Date: 10/24/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1001 BLYTHE BLVD
CHARLOTTE NC
28203-5866
US

IV. Provider business mailing address

1836 MOREHEAD RIDGE DR APT 306
CHARLOTTE NC
28208-5671
US

V. Phone/Fax

Practice location:
  • Phone: 704-381-6100
  • Fax:
Mailing address:
  • Phone: 608-576-3643
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0222X
TaxonomyCritical Care Pediatric Nurse Practitioner
License Number5020894
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: