Provider Demographics
NPI:1407005119
Name:GUPTILL, CHANDA NICOLE (NP)
Entity Type:Individual
Prefix:
First Name:CHANDA
Middle Name:NICOLE
Last Name:GUPTILL
Suffix:
Gender:F
Credentials:NP
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 19305
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28219-9305
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:332 N TRADE ST
Practice Address - Street 2:STE 1500
Practice Address - City:MATTHEWS
Practice Address - State:NC
Practice Address - Zip Code:28105-1728
Practice Address - Country:US
Practice Address - Phone:704-512-6820
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-09-17
Last Update Date:2023-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5004033363L00000X
NC181218 / 5004033363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1407005119Medicaid
SCNP1510Medicaid
NCNC8798BMedicare PIN
SCNP1510Medicaid