Provider Demographics
NPI:1164641908
Name:WILLEFORD, CARLEEN (FNP)
Entity Type:Individual
Prefix:MRS
First Name:CARLEEN
Middle Name:
Last Name:WILLEFORD
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 1:10 DOCTORS CIR
Mailing Address - Street 2:SUITE 2
Mailing Address - City:SUPPLY
Mailing Address - State:NC
Mailing Address - Zip Code:28462-4089
Mailing Address - Country:US
Mailing Address - Phone:910-755-6060
Mailing Address - Fax:910-755-6061
Practice Address - Street 1:10 DOCTORS CIR
Practice Address - Street 2:SUITE 2
Practice Address - City:SUPPLY
Practice Address - State:NC
Practice Address - Zip Code:28462-4089
Practice Address - Country:US
Practice Address - Phone:910-755-6060
Practice Address - Fax:910-755-6061
Is Sole Proprietor?:No
Enumeration Date:2007-04-24
Last Update Date:2012-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC201524363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8987642Medicaid
NC016UXOtherBCBS NC PROVIDER NUMBER
NC2186636DMedicare ID - Type Unspecified
NC8987642Medicaid