MEDICARE: MIA LICOLE SAULTER AGPCNP

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	363L00000X	Nurse Practitioner	5012986	NC
2	363LG0600X	Gerontology Nurse Practitioner	5012986	NC
3	363LP2300X	Primary Care Nurse Practitioner	5012986	NC

General Provider Information

NPI Number	:	1578109427
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MIA LICOLE SAULTER AGPCNP

Provider Business Mailing Address
First Line	:	3961 STAFFORD RUN CT
Second Line	:
City	:	HIGH POINT
State	:	NC
Zip	:	27265-9480
Country	:	US
Telephone Number	:	919-601-2139
Fax Number	:

Provider Business Practice Location Address
First Line	:	3961 STAFFORD RUN CT
Second Line	:
City	:	HIGH POINT
State	:	NC
Zip	:	27265-9480
Country	:	US
Telephone Number	:	919-601-2139
Fax Number	:

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

Provider Enumeration Date	:	11/25/2019
Last Update Date	:	02/13/2025

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