Healthcare Provider Details

I. General information

NPI: 1235347378
Provider Name (Legal Business Name): NORTHLAKE CHILDREN'S ASSOCIATES, P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/21/2007
Last Update Date: 05/02/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

170A MEDICAL PARK RD SUITE 102
MOORESVILLE NC
28117
US

IV. Provider business mailing address

170A MEDICAL PARK RD SUITE 102
MOORESVILLE NC
28117
US

V. Phone/Fax

Practice location:
  • Phone: 704-663-5240
  • Fax: 704-663-5399
Mailing address:
  • Phone: 704-663-5240
  • Fax: 704-663-5399

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number
License Number State

VIII. Authorized Official

Name: BRITTANY SCHIPPER
Title or Position: OFFICE/CLINICAL MANAGER
Credential: R.N.
Phone: 704-663-5240