=====================================================
General NPI Number Information
=====================================================
NPI Number | 1336274513
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DR. JOAN E WILKINS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/21/2007
-----------------------------------------------------
Last Update Date | 09/16/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2422 REYNOLDA RD
-----------------------------------------------------
City | WINSTON SALEM
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27106-4606
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 336-722-7650
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2422 REYNOLDA RD
-----------------------------------------------------
City | WINSTON SALEM
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27106-4606
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 336-722-7650
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 103TC0700X
-----------------------------------------------------
Taxonomy Name | Clinical Psychologist
-----------------------------------------------------
License Number | 823
-----------------------------------------------------
License Number State | NC
-----------------------------------------------------