Healthcare Provider Details

I. General information

NPI: 1063246882
Provider Name (Legal Business Name): SYLVIE A FANDOHAN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/26/2024
Last Update Date: 08/26/2024
Certification Date: 08/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

131 PLANTATION RIDGE DR STE 305
MOORESVILLE NC
28117-9543
US

IV. Provider business mailing address

131 PLANTATION RIDGE DR STE 305
MOORESVILLE NC
28117-9543
US

V. Phone/Fax

Practice location:
  • Phone: 828-540-0112
  • Fax:
Mailing address:
  • Phone: 828-540-0112
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License NumberHC7552
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code385H00000X
TaxonomyRespite Care
License NumberHC7552
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License NumberHC7552
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: