Provider Demographics
NPI:1003854860
Name:PICKETT, MARCIE LYNNE (ANP)
Entity Type:Individual
Prefix:MS
First Name:MARCIE
Middle Name:LYNNE
Last Name:PICKETT
Suffix:
Gender:F
Credentials:ANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 497
Mailing Address - Street 2:
Mailing Address - City:HUNTERSVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28070-0497
Mailing Address - Country:US
Mailing Address - Phone:704-377-4009
Mailing Address - Fax:
Practice Address - Street 1:2015 RANDOLPH RD
Practice Address - Street 2:STE 208
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28207-1200
Practice Address - Country:US
Practice Address - Phone:704-377-4009
Practice Address - Fax:704-377-7406
Is Sole Proprietor?:No
Enumeration Date:2006-06-03
Last Update Date:2019-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5002187363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYP664030Medicare UPIN
NYDD2173Medicare ID - Type Unspecified