Basic Information
| Provider Information | |||||||||
| NPI: | 1912653742 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CLONTZ | ||||||||
| FirstName: | NICHOLE | ||||||||
| MiddleName: | LOWERY | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | AGNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8401 MEDICAL PLAZA DR STE 365 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282628700 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7049440975 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2616 E 5TH ST | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282044343 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7043335165 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/02/2022 | ||||||||
| LastUpdateDate: | 03/02/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/02/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 5015868 | NC | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
ID Information
| ID | Type | State | Issuer | Description | 5015868 | 01 | NC | STATE LICENSING | OTHER |