1194854778 NPI number — MRS. CATHERINE JANELL TEWOLDE CNP

Table of content: MRS. CATHERINE JANELL TEWOLDE CNP (NPI 1194854778)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1194854778 NPI number — MRS. CATHERINE JANELL TEWOLDE CNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TEWOLDE
Provider First Name:
CATHERINE
Provider Middle Name:
JANELL
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
CNP
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:
1194854778
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/04/2015
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
8521 TONAWANDA DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CHARLOTTE
Provider Business Mailing Address State Name:
NC
Provider Business Mailing Address Postal Code:
28277-1802
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
704-668-1555
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
332 SAM NEWELL RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
MATTHEWS
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28105-6566
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
704-302-8583
Provider Business Practice Location Address Fax Number:
704-302-8548
Provider Enumeration Date:
03/02/2007

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: 363LA2200X , with the licence number:  5003379 , 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)

  • Identifier: 7004477 , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".
  • Identifier: NP1296 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".




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