Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
N | 207R00000X | Internist | 066472 | GA |
N | 111NI0900X | Internist | 066472 | GA |
N | 207R00000X | Internist | 201500282 | NC |
N | 111NI0900X | Internist | 201500282 | NC |
N | 207RH0000X | Hematologist | 066472 | GA |
N | 207RH0000X | Hematologist | 201500282 | NC |
Y | 207RH0003X | Hematology & Oncology | 201500282 | NC |
N | 207RX0202X | Medical Oncology | 066472 | GA |
N | 207RX0202X | Medical Oncology | 201500282 | NC |
NPI | 1417046343 |
---|---|
Provider Name | Dr. Jennifer Lauren Dallas |
First Address | Charlotte, NC 28260-0447 |
Second Address | Charlotte, NC 28215-7072 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 11/10/2006 |
Last Update Date | 12/08/2021 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
003114517A | (05) | GA |
NC0074A | (02) | NC |
RES000 | (02) | FL |