Healthcare Provider Details

I. General information

NPI: 1164206447
Provider Name (Legal Business Name): JAQULIN BEDNARCZYK KNAUSS NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/18/2023
Last Update Date: 09/19/2024
Certification Date: 09/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

510 CAROLINA BAY DR STE 100
WILMINGTON NC
28403-2046
US

IV. Provider business mailing address

PO BOX 936857
ATLANTA GA
31193-6857
US

V. Phone/Fax

Practice location:
  • Phone: 910-763-9833
  • Fax: 910-763-5166
Mailing address:
  • Phone: 910-763-9833
  • Fax: 910-763-5166

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number5018658
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number5018658
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: