Healthcare Provider Details

I. General information

NPI: 1568044287
Provider Name (Legal Business Name): MICHELLE LUETTE WANDS NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/22/2021
Last Update Date: 02/25/2026
Certification Date: 02/25/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

721 JETTON ST STE 115
DAVIDSON NC
28036-0359
US

IV. Provider business mailing address

721 JETTON ST STE 115
DAVIDSON NC
28036-0359
US

V. Phone/Fax

Practice location:
  • Phone: 704-255-6167
  • Fax:
Mailing address:
  • Phone: 704-255-6167
  • Fax: 704-255-6168

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number5014357
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: