Basic Information
| Provider Information | |||||||||
| NPI: | 1497242630 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CONGRESS | ||||||||
| FirstName: | JAICIE | ||||||||
| MiddleName: | N | ||||||||
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| Credential: | FNP-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8727 JW CLAY BLVD | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282625417 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9809991831 | ||||||||
| FaxNumber: | 8775368312 | ||||||||
| Practice Location | |||||||||
| Address1: | 8727 JW CLAY BLVD | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282625417 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9809991831 | ||||||||
| FaxNumber: | 8775368312 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/13/2018 | ||||||||
| LastUpdateDate: | 08/23/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 08/23/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 5010457 | NC | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | NN2081H224 | 01 | NC | MEDICARE | OTHER |