Healthcare Provider Details

I. General information

NPI: 1831476613
Provider Name (Legal Business Name): THE WELL FOR HEALTH, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/08/2011
Last Update Date: 12/18/2019
Certification Date: 12/18/2019
Deactivation Date:
Reactivation Date:

III. Provider practice location address

575 DAVIDSON GATEWAY DR STE 100
DAVIDSON NC
28036
US

IV. Provider business mailing address

575 DAVIDSON GATEWAY DR STE 100
DAVIDSON NC
28036-7036
US

V. Phone/Fax

Practice location:
  • Phone: 704-799-5433
  • Fax: 704-706-2446
Mailing address:
  • Phone: 704-799-5433
  • Fax: 704-706-2446

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License Number940100
License Number StateNC

VIII. Authorized Official

Name: DIANE MUDGE PARKS
Title or Position: NURSE PRACTITIONER
Credential: NP
Phone: 704-577-4630