Provider Demographics
NPI:1447424338
Name:VALDIVIEZO, AUXILIADORA KRUPSKAYA (FNP-BC)
Entity Type:Individual
Prefix:
First Name:AUXILIADORA
Middle Name:KRUPSKAYA
Last Name:VALDIVIEZO
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3541 RANDOLPH RD
Mailing Address - Street 2:STE 303
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28211-5122
Mailing Address - Country:US
Mailing Address - Phone:704-333-0465
Mailing Address - Fax:704-333-0466
Practice Address - Street 1:101 W.T. HARRIS BLVD
Practice Address - Street 2:SUITE 1213
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28262-7007
Practice Address - Country:US
Practice Address - Phone:704-549-8997
Practice Address - Fax:704-549-9197
Is Sole Proprietor?:No
Enumeration Date:2008-04-22
Last Update Date:2016-12-10
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NC5003960363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2593277AMedicare PIN
NC2593277BMedicare PIN