Provider Demographics
NPI:1609817931
Name:EARNHARDT, EXIE DIANNE (CRNA)
Entity Type:Individual
Prefix:MRS
First Name:EXIE
Middle Name:DIANNE
Last Name:EARNHARDT
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:DIANNE
Other - Middle Name:P
Other - Last Name:EARNHARDT
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:4400 GOLF ACRES DR
Mailing Address - Street 2:SUITE A
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28208-5968
Mailing Address - Country:US
Mailing Address - Phone:704-355-8231
Mailing Address - Fax:
Practice Address - Street 1:1000 BLYTHE BLVD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28203-5812
Practice Address - Country:US
Practice Address - Phone:704-355-8231
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-09
Last Update Date:2017-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC89930367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8051992Medicaid
SCNAN676Medicaid
NC8051992Medicaid