Provider Demographics
NPI:1932451598
Name:WEATHERLY, STEPHANIE LEIGH (NP)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:LEIGH
Last Name:WEATHERLY
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:PO BOX 470408
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28247-0408
Mailing Address - Country:US
Mailing Address - Phone:704-375-0100
Mailing Address - Fax:704-335-3592
Practice Address - Street 1:7845 LITTLE AVE
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28226-8198
Practice Address - Country:US
Practice Address - Phone:704-375-0100
Practice Address - Fax:704-335-3592
Is Sole Proprietor?:No
Enumeration Date:2012-10-08
Last Update Date:2018-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5005844363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7006425Medicaid