Provider Demographics
NPI:1033176714
Name:WILSON DAVIS, STEPHANIE (RN, MSN)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:WILSON DAVIS
Suffix:
Gender:F
Credentials:RN, MSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 E 2ND AVE
Mailing Address - Street 2:
Mailing Address - City:GASTONIA
Mailing Address - State:NC
Mailing Address - Zip Code:28052-4358
Mailing Address - Country:US
Mailing Address - Phone:704-874-1904
Mailing Address - Fax:
Practice Address - Street 1:4555 OGBURN AVE
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27105-2726
Practice Address - Country:US
Practice Address - Phone:336-703-4273
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-04-27
Last Update Date:2020-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5012785363L00000X
MO2001029398363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
KS100415260AMedicaid
MO425770807Medicaid
KS100415260AMedicaid
P51205Medicare UPIN