=====================================================
General NPI Number Information
=====================================================
NPI Number | 1134900996
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | NICOLE DANIELS FNP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/09/2023
-----------------------------------------------------
Last Update Date | 10/09/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 10650 PARK RD STE 320
-----------------------------------------------------
City | CHARLOTTE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28210-8543
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-248-3400
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1518 E 3RD ST STE 250
-----------------------------------------------------
City | CHARLOTTE
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28204-3192
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-248-3400
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 5018963
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------