Healthcare Provider Details

I. General information

NPI: 1881144590
Provider Name (Legal Business Name): SOUTHERN FAMILY MEDICINE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/05/2016
Last Update Date: 01/14/2026
Certification Date: 01/14/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 E STATESVILLE AVE STE 200
MOORESVILLE NC
28115-2588
US

IV. Provider business mailing address

400 E STATESVILLE AVE STE 200
MOORESVILLE NC
28115-2588
US

V. Phone/Fax

Practice location:
  • Phone: 704-360-8486
  • Fax: 704-230-4674
Mailing address:
  • Phone: 704-360-8486
  • Fax: 704-230-4674

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number StateNULL
# 3
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number StateNULL

VIII. Authorized Official

Name: MRS. ANGELA JARVIS MICOLUCCI
Title or Position: CEO
Credential: LCMHCS
Phone: 704-953-4890