Healthcare Provider Details

I. General information

NPI: 1801634563
Provider Name (Legal Business Name): CARMEN JADE CHILDERS RASZKA NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/17/2024
Last Update Date: 08/11/2026
Certification Date: 08/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2555 COURT DR
GASTONIA NC
28054-2134
US

IV. Provider business mailing address

PO BOX 744786
ATLANTA GA
30374-4786
US

V. Phone/Fax

Practice location:
  • Phone: 704-867-2141
  • Fax: 704-867-2308
Mailing address:
  • Phone: 704-834-2450
  • Fax: 704-671-5331

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number270643
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number5020450
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: