Healthcare Provider Details

I. General information

NPI: 1558703090
Provider Name (Legal Business Name): MARYNA RUDENKO YACINTHE FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/25/2013
Last Update Date: 03/29/2021
Certification Date: 03/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

738 BRYANT ST STE A
STATESVILLE NC
28677-4189
US

IV. Provider business mailing address

738 BRYANT ST STE A
STATESVILLE NC
28677-4189
US

V. Phone/Fax

Practice location:
  • Phone: 704-873-1116
  • Fax:
Mailing address:
  • Phone: 704-682-1875
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number223804
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: