Provider Demographics
NPI:1255428017
Name:MOCKAITIS, KRISTA
Entity type:Individual
Prefix:
First Name:KRISTA
Middle Name:
Last Name:MOCKAITIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7800 PROVIDENCE RD
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28226-2952
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:7800 PROVIDENCE RD
Practice Address - Street 2:SUITE 203
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28226-2952
Practice Address - Country:US
Practice Address - Phone:704-512-2610
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-05
Last Update Date:2019-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5002041363L00000X
NC183255363LP0200X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7005688Medicaid
SCNP3612Medicaid
NC1255428017Medicaid
SCNP3612Medicaid