Healthcare Provider Details

I. General information

NPI: 1548064819
Provider Name (Legal Business Name): DIGITAL HEALTH INNOVATION LEARNING LAB
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/03/2025
Last Update Date: 04/04/2025
Certification Date: 04/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1519 MECKLENBURG HWY UNIT 362
MOORESVILLE NC
28123-2016
US

IV. Provider business mailing address

1519 MECKLENBURG HWY UNIT 362
MOORESVILLE NC
28123-2016
US

V. Phone/Fax

Practice location:
  • Phone: 989-708-0349
  • Fax:
Mailing address:
  • Phone: 989-708-0349
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WC1500X
TaxonomyCommunity Health Registered Nurse
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code1835P0018X
TaxonomyPharmacist Clinician (PhC)/ Clinical Pharmacy Specialist
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code207QA0000X
TaxonomyAdolescent Medicine (Family Medicine) Physician
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number
License Number State
# 7
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 8
Primary TaxonomyN
Taxonomy Code101YS0200X
TaxonomySchool Counselor
License Number
License Number State
# 9
Primary TaxonomyN
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number
License Number State
# 10
Primary TaxonomyN
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License Number
License Number State
# 11
Primary TaxonomyN
Taxonomy Code1223D0001X
TaxonomyPublic Health Dentistry
License Number
License Number State
# 12
Primary TaxonomyN
Taxonomy Code124Q00000X
TaxonomyDental Hygienist
License Number
License Number State
# 13
Primary TaxonomyN
Taxonomy Code363LC1500X
TaxonomyCommunity Health Nurse Practitioner
License Number
License Number State
# 14
Primary TaxonomyN
Taxonomy Code364SC1501X
TaxonomyCommunity Health/Public Health Clinical Nurse Specialist
License Number
License Number State
# 15
Primary TaxonomyY
Taxonomy Code2083P0901X
TaxonomyPublic Health & General Preventive Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: JEANETTE ALLEN
Title or Position: GENERAL MANAGER
Credential: MBA
Phone: 989-708-0349