Basic Information
| Provider Information | |||||||||
| NPI: | 1568772382 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | PHELPS | ||||||||
| FirstName: | JARYN | ||||||||
| MiddleName: | ROYCE | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | AUD | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | PULICE | ||||||||
| OtherFirstName: | JARYN | ||||||||
| OtherMiddleName: | ROYCE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | AUD | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 6035 FAIRVIEW RD | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282103256 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7048388493 | ||||||||
| FaxNumber: | 7048388494 | ||||||||
| Practice Location | |||||||||
| Address1: | 6035 FAIRVIEW RD | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282103256 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7048388493 | ||||||||
| FaxNumber: | 7048388494 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/14/2010 | ||||||||
| LastUpdateDate: | 09/01/2016 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialTitleorPosition: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 231H00000X | 9065 | NC | Y | Speech, Language and Hearing Service Providers | Audiologist | 237600000X | 654BD01 | NC | N | Speech, Language and Hearing Service Providers | Audiologist-Hearing Aid Fitter |
ID Information
| ID | Type | State | Issuer | Description | 774097 | 01 | WELLCARE | OTHER | SAN088 | 05 | SC | MEDICAID | 30110579 | 01 | SC | SELECT HEALTH OF SC | OTHER | 7413427 | 05 | NC | MEDICAID | 9119790 | 01 | AETNA | OTHER | 162CV | 01 | NC | BCBSNC | OTHER | 4492644 | 01 | NC | CIGNA | OTHER |