Provider Demographics
NPI:1831725217
Name:WAXHAW MEDICAL WELLNESS, PLLC
Entity type:Organization
Organization Name:WAXHAW MEDICAL WELLNESS, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:HEATHER
Authorized Official - Middle Name:E
Authorized Official - Last Name:SHIFLETT
Authorized Official - Suffix:
Authorized Official - Credentials:PA
Authorized Official - Phone:704-264-4582
Mailing Address - Street 1:8015 FARMBROOK DR
Mailing Address - Street 2:
Mailing Address - City:WAXHAW
Mailing Address - State:NC
Mailing Address - Zip Code:28173-7123
Mailing Address - Country:US
Mailing Address - Phone:704-264-4582
Mailing Address - Fax:
Practice Address - Street 1:8015 FARMBROOK DR
Practice Address - Street 2:
Practice Address - City:WAXHAW
Practice Address - State:NC
Practice Address - Zip Code:28173-7123
Practice Address - Country:US
Practice Address - Phone:704-264-4582
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-03-18
Last Update Date:2020-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Single Specialty