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General NPI Number Information
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NPI Number | 1720395783
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Entity Type | Organization
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Legal Business Name | LAKE NORMAN PAIN AND WEIGHT MANAGEMENT, LLC
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Dates
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Enumeration Date | 09/10/2010
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Last Update Date | 03/18/2024
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Provider Practice Location Address
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Address Line | 378 WILLIAMSON RD STE 204
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City | MOORESVILLE
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State | NC
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Zip | 28117-5917
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Country | US
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Telephone | 704-662-0009
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Fax | 704-360-2335
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Provider Business Mailing Address
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Address Line | 378 WILLIAMSON RD STE 204
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City | MOORESVILLE
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State | NC
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Zip | 28117-5917
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Country | US
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Telephone | 704-662-0009
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Fax | 704-360-2335
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Authorized Official
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Title or Position | NURSE PRACTITIONER
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Name | MRS. CHRISSY GAYLE FOHR
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Credential | NPC
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Telephone | 336-414-1164
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LA2200X
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Taxonomy Name | Adult Health Nurse Practitioner
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License Number | 5004119
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License Number State | NC
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