Provider Demographics
NPI:1043309198
Name:WILSON, COURTNEY W (FNP)
Entity Type:Individual
Prefix:
First Name:COURTNEY
Middle Name:W
Last Name:WILSON
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 1654
Mailing Address - Street 2:
Mailing Address - City:WRIGHTSVILLE BEACH
Mailing Address - State:NC
Mailing Address - Zip Code:28480-9654
Mailing Address - Country:US
Mailing Address - Phone:910-208-0258
Mailing Address - Fax:910-772-4183
Practice Address - Street 1:6317 OLEANDER DR
Practice Address - Street 2:SUITE A
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28403-3568
Practice Address - Country:US
Practice Address - Phone:910-208-0258
Practice Address - Fax:910-772-4183
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-12
Last Update Date:2011-06-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC201012363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NCQ37704Medicare UPIN
NC2592328Medicare PIN