Provider Demographics
NPI:1568005023
Name:OWENS, NICOLE LEANNE (PA-C)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:LEANNE
Last Name:OWENS
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1339 MARYLAND AVE
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28209-1525
Mailing Address - Country:US
Mailing Address - Phone:843-714-2814
Mailing Address - Fax:
Practice Address - Street 1:1339 MARYLAND AVE
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28209-1525
Practice Address - Country:US
Practice Address - Phone:843-714-2814
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-28
Last Update Date:2022-03-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC0010-11765363A00000X
SC3331363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant