Provider Demographics
NPI:1003932971
Name:WILSON-DURHAM, ELIZABETH OLUDAYO (FNP)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:OLUDAYO
Last Name:WILSON-DURHAM
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 19305
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28219-9305
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1237 HARDING PL
Practice Address - Street 2:STE 3100
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28204
Practice Address - Country:US
Practice Address - Phone:704-373-0212
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-03-22
Last Update Date:2023-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5008512363L00000X, 363LF0000X
TNRN0000117183163WG0000X
IL209009614363LA2100X
TN11927363LF0000X
NC#5008512363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCNP4112Medicaid
NC1003932971Medicaid
NC1003932971Medicaid
SCNP4112Medicaid