Healthcare Provider Details

I. General information

NPI: 1295726602
Provider Name (Legal Business Name): SUSAN MISKOVICH MEHTA FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/03/2005
Last Update Date: 03/28/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

219 LEPHILLIP COURT NE
CONCORD NC
28025-2900
US

IV. Provider business mailing address

219 LEPHILLIP COURT NE
CONCORD NC
28025-2900
US

V. Phone/Fax

Practice location:
  • Phone: 704-403-7770
  • Fax: 704-403-7779
Mailing address:
  • Phone: 704-403-7770
  • Fax: 704-403-7779

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WP2201X
TaxonomyAmbulatory Care Registered Nurse
License Number076981
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number67386
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: