Provider Demographics
NPI:1720803497
Name:STREET, SARAH JORDYN-MARY (FNP-C)
Entity type:Individual
Prefix:
First Name:SARAH
Middle Name:JORDYN-MARY
Last Name:STREET
Suffix:
Gender:F
Credentials:FNP-C
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 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6324 FAIRVIEW RD STE 201
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28210-4278
Practice Address - Country:US
Practice Address - Phone:704-384-0588
Practice Address - Fax:704-384-0580
Is Sole Proprietor?:No
Enumeration Date:2024-11-18
Last Update Date:2025-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5021219363LP2300X, 363L00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program