Healthcare Provider Details

I. General information

NPI: 1548100506
Provider Name (Legal Business Name): VICTORIA WILSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/30/2026
Last Update Date: 03/30/2026
Certification Date: 03/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

39 WINECOFF AVE NW STE 1
CONCORD NC
28025-4427
US

IV. Provider business mailing address

39 WINECOFF AVE NW STE 1
CONCORD NC
28025-4427
US

V. Phone/Fax

Practice location:
  • Phone: 216-240-2637
  • Fax:
Mailing address:
  • Phone: 216-240-2637
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License NumberC115849
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: