Basic Information
| Provider Information | |||||||||
| NPI: | 1871918375 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | SACKSTEDER | ||||||||
| FirstName: | KYLEE | ||||||||
| MiddleName: | NICOLE | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1072 XRAY DR | ||||||||
| Address2: | |||||||||
| City: | GASTONIA | ||||||||
| State: | NC | ||||||||
| PostalCode: | 28054 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7046711094 | ||||||||
| FaxNumber: | 7046711095 | ||||||||
| Practice Location | |||||||||
| Address1: | 309 S SHARON AMITY RD STE 200 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282112886 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7043448846 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/20/2014 | ||||||||
| LastUpdateDate: | 12/12/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 12/12/2019 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207N00000X | 201702355 | NC | Y | Allopathic & Osteopathic Physicians | Dermatology |
No ID Information.