Healthcare Provider Details

I. General information

NPI: 1134062441
Provider Name (Legal Business Name): GWEN WELLER FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/11/2026
Last Update Date: 04/11/2026
Certification Date: 04/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3650 EXPRESS DR
SHALLOTTE NC
28470-6501
US

IV. Provider business mailing address

3650 EXPRESS DR
SHALLOTTE NC
28470-6501
US

V. Phone/Fax

Practice location:
  • Phone: 910-754-2229
  • Fax: 910-754-2217
Mailing address:
  • Phone: 910-754-2229
  • Fax: 910-754-2217

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number5024174
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: