Provider Demographics
NPI:1457698326
Name:SAFE HAVEN HOME FOR GIRLS, PLLC
Entity Type:Organization
Organization Name:SAFE HAVEN HOME FOR GIRLS, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FAMILY NURSE PRACTITIONER
Authorized Official - Prefix:MRS
Authorized Official - First Name:KIM
Authorized Official - Middle Name:R
Authorized Official - Last Name:ENGLISH
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:980-201-1422
Mailing Address - Street 1:9338 AMES HOLLOW RD
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28216-8787
Mailing Address - Country:US
Mailing Address - Phone:704-509-4540
Mailing Address - Fax:704-509-4540
Practice Address - Street 1:9338 AMES HOLLOW RD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28216-8787
Practice Address - Country:US
Practice Address - Phone:980-201-1422
Practice Address - Fax:980-201-1422
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-01-11
Last Update Date:2017-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5004910363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7005736Medicaid