Healthcare Provider Details

I. General information

NPI: 1053209841
Provider Name (Legal Business Name): EMMANUELLE VANESSA CAMILLE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2025
Last Update Date: 04/02/2026
Certification Date: 04/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 BLYTHE BLVD STE 601
CHARLOTTE NC
28203-5812
US

IV. Provider business mailing address

475 VINE ST
WINSTON SALEM NC
27101-4135
US

V. Phone/Fax

Practice location:
  • Phone: 704-355-7874
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: