Healthcare Provider Details

I. General information

NPI: 1730072711
Provider Name (Legal Business Name): COREY-MICHAEL WILCOX FNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/30/2025
Last Update Date: 12/17/2025
Certification Date: 12/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 FODEN RD STE 203
SOUTH PORTLAND ME
04106-2327
US

IV. Provider business mailing address

100 GANNETT DR STE C
SOUTH PORTLAND ME
04106-5900
US

V. Phone/Fax

Practice location:
  • Phone: 207-874-1489
  • Fax:
Mailing address:
  • Phone: 207-347-2947
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberCNP251322
License Number StateME
# 2
Primary TaxonomyN
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License NumberCNP251322
License Number StateME

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: