1629317987 NPI number — MRS. LAURA ANNE THEUNISSE PT

Table of content: MRS. LAURA ANNE THEUNISSE PT (NPI 1629317987)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629317987 NPI number — MRS. LAURA ANNE THEUNISSE PT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
THEUNISSE
Provider First Name:
LAURA
Provider Middle Name:
ANNE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
PT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1629317987
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
09/15/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8832 BLAKENEY PROFESSIONAL DR
Provider Second Line Business Mailing Address:
SUITE 100
Provider Business Mailing Address City Name:
CHARLOTTE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28277-6809
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
704-817-6718
Provider Business Mailing Address Fax Number:
704-817-7887

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
13635 PROVIDENCE RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WEDDINGTON
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28104
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
704-457-0043
Provider Business Practice Location Address Fax Number:
704-814-0224
Provider Enumeration Date:
02/06/2013

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 2251X0800X , with the licence number:  P10953 , registered in the state of NC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)