Provider Demographics
NPI:1699700484
Name:HEAD, MARY C (NP)
Entity type:Individual
Prefix:
First Name:MARY
Middle Name:C
Last Name:HEAD
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:457 N WENDOVER RD
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28211-1064
Mailing Address - Country:US
Mailing Address - Phone:704-817-3808
Mailing Address - Fax:877-471-2522
Practice Address - Street 1:457 N WENDOVER RD
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28211-1064
Practice Address - Country:US
Practice Address - Phone:704-817-3808
Practice Address - Fax:877-471-2522
Is Sole Proprietor?:No
Enumeration Date:2006-07-11
Last Update Date:2025-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC900417363L00000X, 363LA2200X
NC0009-00417208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No208600000XAllopathic & Osteopathic PhysiciansSurgery
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7003510Medicaid
NC2592093EMedicare PIN
NCQ17142Medicare UPIN
NC2592093Medicare ID - Type Unspecified
NC2592093AMedicare PIN