Healthcare Provider Details

I. General information

NPI: 1568085124
Provider Name (Legal Business Name): STACY ELIZABETH CARLSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/18/2020
Last Update Date: 06/04/2025
Certification Date: 06/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10620 PARK RD STE 202
CHARLOTTE NC
28210-0106
US

IV. Provider business mailing address

325 OLD STANCIL RD
KENLY NC
27542-5011
US

V. Phone/Fax

Practice location:
  • Phone: 844-235-6999
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number5016676
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: