Healthcare Provider Details

I. General information

NPI: 1760326813
Provider Name (Legal Business Name): MACKILLOP MIND 2 P.L.L.C
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/17/2026
Last Update Date: 04/17/2026
Certification Date: 04/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8004 COTTON ROSE CT
WILMINGTON NC
28412-1402
US

IV. Provider business mailing address

8004 COTTON ROSE CT
WILMINGTON NC
28412-1402
US

V. Phone/Fax

Practice location:
  • Phone: 631-987-3011
  • Fax:
Mailing address:
  • Phone: 631-987-3011
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name: YVONNE MACKILLOP
Title or Position: OWNER/ CEO
Credential: PA-C
Phone: 631-987-3011