Healthcare Provider Details

I. General information

NPI: 1295366904
Provider Name (Legal Business Name): JESSICA KNADLER
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/31/2020
Last Update Date: 01/31/2020
Certification Date: 01/31/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

132 WINDSOR LN
RAEFORD NC
28376-8251
US

IV. Provider business mailing address

132 WINDSOR LN
RAEFORD NC
28376-8251
US

V. Phone/Fax

Practice location:
  • Phone: 910-273-8777
  • Fax:
Mailing address:
  • Phone: 910-273-8777
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3747A0650X
TaxonomyAttendant Care Provider
License Number
License Number StateNC

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: