Provider Demographics
NPI:1346879434
Name:WILSON, MYRA VAUGHTERS
Entity Type:Individual
Prefix:
First Name:MYRA
Middle Name:VAUGHTERS
Last Name:WILSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1320 LANDSDOWN DR
Mailing Address - Street 2:
Mailing Address - City:SALISBURY
Mailing Address - State:NC
Mailing Address - Zip Code:28147-7373
Mailing Address - Country:US
Mailing Address - Phone:336-682-8968
Mailing Address - Fax:980-330-3432
Practice Address - Street 1:1320 LANDSDOWN DR
Practice Address - Street 2:
Practice Address - City:SALISBURY
Practice Address - State:NC
Practice Address - Zip Code:28147-7373
Practice Address - Country:US
Practice Address - Phone:336-682-8968
Practice Address - Fax:980-330-3432
Is Sole Proprietor?:No
Enumeration Date:2020-04-02
Last Update Date:2020-04-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No172V00000XOther Service ProvidersCommunity Health Worker