=====================================================
General NPI Number Information
=====================================================
NPI Number | 1588115976
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | KANNAPOLIS INTERNAL MEDICINE
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/20/2016
-----------------------------------------------------
Last Update Date | 10/20/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 201 DALE EARNHARDT BLVD SUITE 200
-----------------------------------------------------
City | KANNAPOLIS
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28081-0303
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-403-7300
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 201 DALE EARNHARDT BLVD SUITE 200
-----------------------------------------------------
City | KANNAPOLIS
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 28081-0303
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 704-403-7300
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CLINICAL PHARMACIST LEADER
-----------------------------------------------------
Name | DR. LINDSAY LOGAN SHEEHAN
-----------------------------------------------------
Credential | PHARMD, CDE, CPP
-----------------------------------------------------
Telephone | 704-403-7300
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number | 21209
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------