MEDICARE: RENEWED AXIS TELEHEALTH PLLC

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	261QM0801X	Mental Health Clinic/Center (Including Community Mental Health Center)
2	261QP2300X	Primary Care Clinic/Center

General Provider Information

NPI Number	:	1063301612
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	RENEWED AXIS TELEHEALTH PLLC

Provider Business Mailing Address
First Line	:	2101 SARDIS RD N STE 120B
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28227-7711
Country	:	US
Telephone Number	:	508-840-2926
Fax Number	:

Provider Business Practice Location Address
First Line	:	2101 SARDIS RD N STE 120B
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28227-7711
Country	:	US
Telephone Number	:	704-840-2927
Fax Number	:

Authorized Official
Title or Position	:	OWNER/PROVIDER
Name	:	NINA FOMBUH
Credential	:	FNP-BC
Telephone Number	:	47-741-2909

Provider Enumeration Date	:	06/30/2025
Last Update Date	:	01/06/2026

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