Healthcare Provider Details

I. General information

NPI: 1194361923
Provider Name (Legal Business Name): WILMINGTON FAMILY PRACTICE PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/27/2019
Last Update Date: 12/12/2024
Certification Date: 12/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3971 BUSINESS 17 E
BOLIVIA NC
28422-8675
US

IV. Provider business mailing address

3971 BUSINESS 17 E
BOLIVIA NC
28422-8675
US

V. Phone/Fax

Practice location:
  • Phone: 910-500-6451
  • Fax: 910-500-6458
Mailing address:
  • Phone: 910-500-6451
  • Fax: 910-500-6458

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207QA0401X
TaxonomyAddiction Medicine (Family Medicine) Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: ANNETTE CROUSE
Title or Position: OFFICE MANAGER
Credential:
Phone: 910-500-6451