Provider Demographics
NPI:1063301612
Name:RENEWED AXIS TELEHEALTH PLLC
Entity type:Organization
Organization Name:RENEWED AXIS TELEHEALTH PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PROVIDER
Authorized Official - Prefix:
Authorized Official - First Name:NINA
Authorized Official - Middle Name:
Authorized Official - Last Name:FOMBUH
Authorized Official - Suffix:
Authorized Official - Credentials:FNP-BC
Authorized Official - Phone:047-741-2909
Mailing Address - Street 1:9114 ARDREY WOODS DR
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28277-1942
Mailing Address - Country:US
Mailing Address - Phone:508-840-2926
Mailing Address - Fax:
Practice Address - Street 1:9114 ARDREY WOODS DR
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28277-1942
Practice Address - Country:US
Practice Address - Phone:704-741-2909
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2025-06-30
Last Update Date:2025-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care
No261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)