Healthcare Provider Details

I. General information

NPI: 1164641908
Provider Name (Legal Business Name): CARLEEN WILLEFORD DNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/24/2007
Last Update Date: 11/06/2025
Certification Date: 11/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

416 MAIN ST
NORTH MYRTLE BEACH SC
29582-3024
US

IV. Provider business mailing address

10 DOCTORS CIR SUITE 2
SUPPLY NC
28462-4089
US

V. Phone/Fax

Practice location:
  • Phone: 843-663-0933
  • Fax: 843-663-0936
Mailing address:
  • Phone: 910-755-6060
  • Fax: 910-755-6061

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPN3204RX
License Number StateSC
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number201524
License Number StateNC
# 3
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number3024
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: