Provider Demographics
NPI:1740970797
Name:STORY, DANITA
Entity type:Individual
Prefix:
First Name:DANITA
Middle Name:
Last Name:STORY
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 1:1216 CAMP GREENE ST
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28208-4012
Mailing Address - Country:US
Mailing Address - Phone:704-396-1849
Mailing Address - Fax:
Practice Address - Street 1:1216 CAMP GREENE ST
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28208-4012
Practice Address - Country:US
Practice Address - Phone:704-396-1849
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-12
Last Update Date:2023-06-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC000035095121172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver