Healthcare Provider Details

I. General information

NPI: 1053069187
Provider Name (Legal Business Name): MARY CAMERON FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/17/2022
Last Update Date: 08/08/2022
Certification Date: 08/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1415 PHYSICIANS DR
WILMINGTON NC
28401-7338
US

IV. Provider business mailing address

PO BOX 936857
ATLANTA GA
31193-6857
US

V. Phone/Fax

Practice location:
  • Phone: 910-662-9500
  • Fax: 910-662-9501
Mailing address:
  • Phone: 910-662-9500
  • Fax: 910-662-9501

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number5016281
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberF03220095
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number237151
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: