Provider Demographics
NPI:1689902777
Name:SROKA, JACQUELINE ANNETTE (NP-C)
Entity Type:Individual
Prefix:MRS
First Name:JACQUELINE
Middle Name:ANNETTE
Last Name:SROKA
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:JACQUELINE
Other - Middle Name:ANNETTE
Other - Last Name:FUGIEL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 601372
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-1372
Mailing Address - Country:US
Mailing Address - Phone:704-446-1242
Mailing Address - Fax:704-446-1241
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:704-446-1242
Practice Address - Fax:704-446-1241
Is Sole Proprietor?:No
Enumeration Date:2009-11-30
Last Update Date:2012-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC204903363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCNP1574Medicaid
NC7005234Medicaid
NC7005234Medicaid