Healthcare Provider Details

I. General information

NPI: 1215205539
Provider Name (Legal Business Name): AVE MARIA FAMILY PRACTICE, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/01/2011
Last Update Date: 07/17/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1230 MEDICAL CENTER DR
WILMINGTON NC
28401
US

IV. Provider business mailing address

PO BOX 16663
WILMINGTON NC
28408-6663
US

V. Phone/Fax

Practice location:
  • Phone: 910-799-5452
  • Fax: 910-799-5479
Mailing address:
  • Phone: 910-799-5452
  • Fax: 910-799-5479

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number2009-01999
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number179288
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number2009-01999
License Number StateNC

VIII. Authorized Official

Name: DR. DOROTHY EJINKONYE AGBAFE-MOSLEY
Title or Position: MEDICAL DIRECTOR
Credential: MD
Phone: 910-799-5452