Healthcare Provider Details

I. General information

NPI: 1336939255
Provider Name (Legal Business Name): WANDA WILSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

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

III. Provider practice location address

2020 ROTHMULLAN DR
CHARLOTTE NC
28262-9265
US

IV. Provider business mailing address

277 BILTMORE AVE
ASHEVILLE NC
28801-4157
US

V. Phone/Fax

Practice location:
  • Phone: 704-497-7114
  • Fax:
Mailing address:
  • Phone: 877-277-8873
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code364SP0809X
TaxonomyAdult Psychiatric/Mental Health Clinical Nurse Specialist
License Number151070
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: