Provider Demographics
NPI:1326204280
Name:BENTIVEGNA, NICOLE M (NP-C)
Entity Type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:M
Last Name:BENTIVEGNA
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1245 BROUGH HALL DR
Mailing Address - Street 2:
Mailing Address - City:WAXHAW
Mailing Address - State:NC
Mailing Address - Zip Code:28173-6937
Mailing Address - Country:US
Mailing Address - Phone:804-814-2483
Mailing Address - Fax:
Practice Address - Street 1:3125 SPRINGBANK LN STE A
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28226-3379
Practice Address - Country:US
Practice Address - Phone:704-752-9346
Practice Address - Fax:704-943-0641
Is Sole Proprietor?:No
Enumeration Date:2008-07-31
Last Update Date:2020-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024167921363LW0102X
NC5006674363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health