Healthcare Provider Details

I. General information

NPI: 1245154541
Provider Name (Legal Business Name): KENSLEY WYATT PHARMD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/07/2026
Last Update Date: 08/07/2026
Certification Date: 08/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4420 LAKE BOONE TRL
RALEIGH NC
27607-7505
US

IV. Provider business mailing address

5653 WADE PARK BLVD
RALEIGH NC
27607-6023
US

V. Phone/Fax

Practice location:
  • Phone: 919-784-3100
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183500000X
TaxonomyPharmacist
License Number34774
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: