Healthcare Provider Details

I. General information

NPI: 1063234037
Provider Name (Legal Business Name): NICOLE WIRTH HARRY PMHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: NICOLE HENSEY WIRTH

II. Dates (important events)

Enumeration Date: 10/30/2024
Last Update Date: 04/10/2026
Certification Date: 04/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

90 GUARDIAN CT
ROCKY MOUNT NC
27804-3017
US

IV. Provider business mailing address

115 PLANTERS WALK
HAMPSTEAD NC
28443-5712
US

V. Phone/Fax

Practice location:
  • Phone: 252-212-3350
  • Fax: 910-226-6534
Mailing address:
  • Phone: 910-548-3022
  • Fax: 910-226-6534

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number5021083
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: