Healthcare Provider Details

I. General information

NPI: 1801948997
Provider Name (Legal Business Name): MARIGOLD PACKHEISER NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/17/2007
Last Update Date: 01/04/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2334 S 41ST ST
WILMINGTON NC
28403-5502
US

IV. Provider business mailing address

5500 N WARRENDALE CT
WILMINGTON NC
28409-4015
US

V. Phone/Fax

Practice location:
  • Phone: 336-908-3462
  • Fax:
Mailing address:
  • Phone: 336-908-3462
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number600076
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: