Provider Demographics
NPI:1104056167
Name:DRAKE, JENNIFER M (ANP-BC)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:M
Last Name:DRAKE
Suffix:
Gender:F
Credentials:ANP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:249 WILLIAMSON RD
Mailing Address - Street 2:SUITE 101
Mailing Address - City:MOORESVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28117-8195
Mailing Address - Country:US
Mailing Address - Phone:704-360-4564
Mailing Address - Fax:704-360-4553
Practice Address - Street 1:131 WELTON WAY
Practice Address - Street 2:
Practice Address - City:MOORESVILLE
Practice Address - State:NC
Practice Address - Zip Code:28117-9163
Practice Address - Country:US
Practice Address - Phone:704-360-4564
Practice Address - Fax:704-360-4553
Is Sole Proprietor?:No
Enumeration Date:2009-07-23
Last Update Date:2018-02-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5004397363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner