Basic Information
| Provider Information | |||||||||
| NPI: | 1932451598 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WEATHERLY | ||||||||
| FirstName: | STEPHANIE | ||||||||
| MiddleName: | LEIGH | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 470408 | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282470408 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7043750100 | ||||||||
| FaxNumber: | 7043353592 | ||||||||
| Practice Location | |||||||||
| Address1: | 7845 LITTLE AVE | ||||||||
| Address2: | |||||||||
| City: | CHARLOTTE | ||||||||
| State: | NC | ||||||||
| PostalCode: | 282268198 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7043750100 | ||||||||
| FaxNumber: | 7043353592 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/08/2012 | ||||||||
| LastUpdateDate: | 04/24/2018 | ||||||||
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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 | 363LA2200X | 5005844 | NC | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Adult Health |
ID Information
| ID | Type | State | Issuer | Description | 7006425 | 05 | NC | MEDICAID |