MEDICARE: MRS. NICOLE M BENTIVEGNA NP-C

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	363LW0102X	Women's Health Nurse Practitioner	0024167921	VA
2	363LA2200X	Adult Health Nurse Practitioner	5006674	NC

General Provider Information

NPI Number	:	1326204280
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. NICOLE M BENTIVEGNA NP-C

Provider Business Mailing Address
First Line	:	1245 BROUGH HALL DR
Second Line	:
City	:	WAXHAW
State	:	NC
Zip	:	28173-6937
Country	:	US
Telephone Number	:	804-814-2483
Fax Number	:

Provider Business Practice Location Address
First Line	:	3125 SPRINGBANK LN STE A
Second Line	:
City	:	CHARLOTTE
State	:	NC
Zip	:	28226-3379
Country	:	US
Telephone Number	:	704-752-9346
Fax Number	:	704-943-0641

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

Provider Enumeration Date	:	07/31/2008
Last Update Date	:	06/23/2020

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