Provider Demographics
NPI:1215961131
Name:SCACCIA, NICOLE M (FNP)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:M
Last Name:SCACCIA
Suffix:
Gender:F
Credentials:FNP
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 19305
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28219-9305
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:420 PARK ST
Practice Address - Street 2:
Practice Address - City:BELMONT
Practice Address - State:NC
Practice Address - Zip Code:28012-3393
Practice Address - Country:US
Practice Address - Phone:704-631-1820
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2023-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC18260363L00000X
NC5000972363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7003766Medicaid