Healthcare Provider Details

I. General information

NPI: 1912924663
Provider Name (Legal Business Name): STACY KUCHARCZK CPNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/17/2006
Last Update Date: 12/11/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1735 CITY CENTER BLVD
ELIZABETH CITY NC
27909-8960
US

IV. Provider business mailing address

1735 CITY CENTER BLVD
ELIZABETH CITY NC
27909-8960
US

V. Phone/Fax

Practice location:
  • Phone: 252-338-2155
  • Fax: 252-338-7704
Mailing address:
  • Phone: 252-338-2155
  • Fax: 252-338-7704

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number5004933
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: