MEDICARE: MRS. CARLEEN WILLEFORD DNP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	APN3204RX	SC
2	363LF0000X	Family Nurse Practitioner	201524	NC
3	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	3024	SC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	016UX	OTHER	NC	BCBS NC PROVIDER NUMBER
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1164641908
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. CARLEEN WILLEFORD DNP

Provider Business Mailing Address
First Line	:	10 DOCTORS CIR
Second Line	:	SUITE 2
City	:	SUPPLY
State	:	NC
Zip	:	28462-4089
Country	:	US
Telephone Number	:	910-755-6060
Fax Number	:	910-755-6061

Provider Business Practice Location Address
First Line	:	416 MAIN ST
Second Line	:
City	:	NORTH MYRTLE BEACH
State	:	SC
Zip	:	29582-3024
Country	:	US
Telephone Number	:	843-663-0933
Fax Number	:	843-663-0936

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/24/2007
Last Update Date	:	11/06/2025

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