Healthcare Provider Details

I. General information

NPI: 1053172205
Provider Name (Legal Business Name): KORTNEY WILSON CLARK FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/16/2024
Last Update Date: 05/12/2026
Certification Date: 05/12/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10101 SAFFIR CT
MINT HILL NC
28227-8949
US

IV. Provider business mailing address

10101 SAFFIR CT
MINT HILL NC
28227-8949
US

V. Phone/Fax

Practice location:
  • Phone: 704-254-6866
  • Fax:
Mailing address:
  • Phone: 704-254-6866
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number5019439
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: