Healthcare Provider Details

I. General information

NPI: 1467388348
Provider Name (Legal Business Name): QUANTAYJIA SHANAY WILFORD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/19/2026
Last Update Date: 07/31/2026
Certification Date: 07/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

202 SMOKETREE WAY
LOUISBURG NC
27549-2165
US

IV. Provider business mailing address

932 GREEN GABLE DR
ZEBULON NC
27597-4436
US

V. Phone/Fax

Practice location:
  • Phone: 919-496-2188
  • Fax:
Mailing address:
  • Phone: 252-661-0964
  • Fax: 252-661-0964

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number5025004
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: