Provider Demographics
NPI:1912653742
Name:CLONTZ, NICHOLE LOWERY (AGNP)
Entity Type:Individual
Prefix:MRS
First Name:NICHOLE
Middle Name:LOWERY
Last Name:CLONTZ
Suffix:
Gender:F
Credentials:AGNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8401 MEDICAL PLAZA DR STE 365
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28262-8700
Mailing Address - Country:US
Mailing Address - Phone:704-944-0975
Mailing Address - Fax:
Practice Address - Street 1:2616 E 5TH ST
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28204-4343
Practice Address - Country:US
Practice Address - Phone:704-333-5165
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-02
Last Update Date:2022-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5015868363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC5015868OtherSTATE LICENSING