MEDICARE: AVITA WADE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	164W00000X	Licensed Practical Nurse	089017	NC

General Provider Information

NPI Number	:	1023608957
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	AVITA WADE

Provider Business Mailing Address
First Line	:	5110 MISTY OAKS DR APT 1813
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28269-4397
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5110 MISTY OAKS DR APT 1813
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28269-4397
Country	:	US
Telephone Number	:	843-641-8326
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/25/2021
Last Update Date	:	01/25/2021

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Directions to “ AVITA WADE ” Practice Location

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