Healthcare Provider Details

I. General information

NPI: 1396653267
Provider Name (Legal Business Name): LINDSEY FETTEROLF
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2026
Last Update Date: 08/31/2026
Certification Date: 08/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2511 LYDIA AVE
CHARLOTTE NC
28205-1907
US

IV. Provider business mailing address

2511 LYDIA AVE
CHARLOTTE NC
28205-1907
US

V. Phone/Fax

Practice location:
  • Phone: 586-604-8704
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number160185
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: