Healthcare Provider Details

I. General information

NPI: 1548775950
Provider Name (Legal Business Name): AGNES EWO MIHNGHA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: AGNES EWO MIHNGHA KEDZE

II. Dates (important events)

Enumeration Date: 12/07/2017
Last Update Date: 06/16/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

407 W KING ST
KINGS MTN NC
28086
US

IV. Provider business mailing address

3139 SUDBURY RD
CHARLOTTE NC
28205-4316
US

V. Phone/Fax

Practice location:
  • Phone: 704-730-8461
  • Fax: 704-730-8349
Mailing address:
  • Phone: 704-890-7799
  • Fax: 704-394-3395

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number5010069
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: