Healthcare Provider Details

I. General information

NPI: 1073925525
Provider Name (Legal Business Name): VANISHA ROCHELLE WILSON M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/02/2014
Last Update Date: 08/13/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

40 DUKE MEDICINE CIR
DURHAM NC
27710
US

IV. Provider business mailing address

200 TRENT DRIVE DUMC BOX 3084
DURHAM NC
27710-0001
US

V. Phone/Fax

Practice location:
  • Phone: 919-684-2471
  • Fax: 919-681-7598
Mailing address:
  • Phone: 919-668-0296
  • Fax: 919-681-0739

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207V00000X
TaxonomyObstetrics & Gynecology Physician
License Number2018-00592
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: