Basic Information
| Provider Information | |||||||||
| NPI: | 1699700484 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | HEAD | ||||||||
| FirstName: | MARY | ||||||||
| MiddleName: | C | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 602362 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282602362 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7043841775 | ||||||||
| FaxNumber: | 7043841776 | ||||||||
| Practice Location | |||||||||
| Address1: | 19485 OLD JETTON RD | ||||||||
| Address2: | SUITE 100 | ||||||||
| City: | CORNELIUS | ||||||||
| State: | NC | ||||||||
| PostalCode: | 280316582 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7043841775 | ||||||||
| FaxNumber: | 7043841776 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/11/2006 | ||||||||
| LastUpdateDate: | 06/21/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 0009-00417 | NC | N | Allopathic & Osteopathic Physicians | Surgery | 363LA2200X | 900417 | NC | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health | 363L00000X | 900417 | NC | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 7003510 | 05 | NC | MEDICAID |