Healthcare Provider Details

I. General information

NPI: 1871140319
Provider Name (Legal Business Name): NONI GAZELLE JEFFERSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/20/2019
Last Update Date: 10/17/2023
Certification Date: 10/17/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2030 WINDSOR RUN LN
MATTHEWS NC
28105-0054
US

IV. Provider business mailing address

5730 EXECUTIVE DR STE 230
CATONSVILLE MD
21228-1762
US

V. Phone/Fax

Practice location:
  • Phone: 704-443-6250
  • Fax:
Mailing address:
  • Phone: 704-443-6250
  • Fax: 704-443-6279

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number248305
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number5012215
License Number StateNC
# 3
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number5012215
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: