Healthcare Provider Details

I. General information

NPI: 1972807790
Provider Name (Legal Business Name): JEANETTE ELIZABETH WILSON DEFELICE FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/08/2011
Last Update Date: 09/27/2021
Certification Date: 09/27/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1240 HUFFMAN MILL ROAD
BURLINGTON NC
27215-8700
US

IV. Provider business mailing address

PO BOX 602598
CHARLOTTE NC
28260-2598
US

V. Phone/Fax

Practice location:
  • Phone: 336-538-8471
  • Fax: 336-538-8161
Mailing address:
  • Phone: 336-716-2255
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number5005058
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: