Individual
FANTA GASSAMA
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Contact information
Practice address
8801 J M KEYNES DR STE 230, CHARLOTTE, NC 28262-5514
(704) 549-1700
Mailing address
8801 J M KEYNES DR STE 230, CHARLOTTE, NC 28262-5514
Taxonomy
Speciality
Code
Description
License number
State
163W00000X
Registered Nurse
Primary
284465
NC
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
000044608353
DRIVER'S LICENSE
NC
Enumeration date
04/22/2019
Last updated
04/22/2019
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