Healthcare Provider Details

I. General information

NPI: 1942591235
Provider Name (Legal Business Name): MINDY RENEE JENKINS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/21/2011
Last Update Date: 04/21/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1408 E. FRANKLIN ST.
MONROE NC
28112-5160
US

IV. Provider business mailing address

284 EXECUTIVE PARK DRIVE SUITE 100
CONCORD NC
28025-1894
US

V. Phone/Fax

Practice location:
  • Phone: 704-635-2080
  • Fax:
Mailing address:
  • Phone: 704-939-1118
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number243814
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: