Healthcare Provider Details

I. General information

NPI: 1780083113
Provider Name (Legal Business Name): JENNA HOLLAND KING WILSON CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/21/2014
Last Update Date: 10/03/2022
Certification Date: 10/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 MATTHEWS TOWNSHIP PKWY
MATTHEWS NC
28105-4656
US

IV. Provider business mailing address

1500 MATTHEWS TOWNSHIP PKWY
MATTHEWS NC
28105-4656
US

V. Phone/Fax

Practice location:
  • Phone: 704-384-6500
  • Fax:
Mailing address:
  • Phone: 704-384-6500
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number104668
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: