Provider Demographics
NPI:1114529070
Name:HARRIS, GWEN CHRISTINE (FNP)
Entity Type:Individual
Prefix:
First Name:GWEN
Middle Name:CHRISTINE
Last Name:HARRIS
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 602195
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-2195
Mailing Address - Country:US
Mailing Address - Phone:919-350-0351
Mailing Address - Fax:919-350-7687
Practice Address - Street 1:2001 S MAIN ST
Practice Address - Street 2:
Practice Address - City:WAKE FOREST
Practice Address - State:NC
Practice Address - Zip Code:27587-1652
Practice Address - Country:US
Practice Address - Phone:919-350-0365
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-14
Last Update Date:2022-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2020067191363LF0000X
NC5015303363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1114529070Medicaid