1629561386 NPI number — ELLEN APNESETH WATSON WOZNIAK AUD

Table of content: ELLEN APNESETH WATSON WOZNIAK AUD (NPI 1629561386)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629561386 NPI number — ELLEN APNESETH WATSON WOZNIAK AUD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WATSON WOZNIAK
Provider First Name:
ELLEN
Provider Middle Name:
APNESETH
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
AUD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
WATSON
Provider Other First Name:
ELLEN
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1629561386
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/29/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6035 FAIRVIEW RD
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:
28210-3256
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
704-295-3643
Provider Business Mailing Address Fax Number:
704-838-8494

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
5933 BLAKENEY PARK DR STE 200
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
CHARLOTTE
Provider Business Practice Location Address State Name:
NC
Provider Business Practice Location Address Postal Code:
28277-5763
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
704-295-3311
Provider Business Practice Location Address Fax Number:
704-295-3322
Provider Enumeration Date:
06/07/2018

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: 231H00000X , with the licence number:  13050 , 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: PENDING , issued by the state of ( NC ) . This identifiers is of the category "MEDICAID".




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