Healthcare Provider Details

I. General information

NPI: 1689316945
Provider Name (Legal Business Name): DONNA COLLINS WILSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/08/2022
Last Update Date: 04/08/2022
Certification Date: 04/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1504 JAKE ALEXANDER BLVD W
SALISBURY NC
28147-1213
US

IV. Provider business mailing address

1254 PINE TOP RD
LEXINGTON NC
27295-6265
US

V. Phone/Fax

Practice location:
  • Phone: 704-645-8539
  • Fax: 704-645-9003
Mailing address:
  • Phone: 336-423-1391
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WA0400X
TaxonomyAddiction (Substance Use Disorder) Registered Nurse
License Number165699
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: