Healthcare Provider Details

I. General information

NPI: 1134825433
Provider Name (Legal Business Name): NICOLE MARIE ELY FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/07/2023
Last Update Date: 02/07/2025
Certification Date: 02/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

237 MULBERRY ST
SHALLOTTE NC
28470-4471
US

IV. Provider business mailing address

237 MULBERRY ST
SHALLOTTE NC
28470-4471
US

V. Phone/Fax

Practice location:
  • Phone: 910-754-8858
  • Fax:
Mailing address:
  • Phone: 910-754-8858
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number11032746
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberSP031398
License Number StatePA
# 3
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number29756
License Number StateSC
# 4
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number5017617
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: