Provider Demographics
NPI:1396396693
Name:WILSON, PHYLLIS NEWSOME
Entity Type:Individual
Prefix:MRS
First Name:PHYLLIS
Middle Name:NEWSOME
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 1:8423 EMPRESS CT
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28227-3624
Mailing Address - Country:US
Mailing Address - Phone:980-254-1778
Mailing Address - Fax:
Practice Address - Street 1:8423 EMPRESS CT
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28227
Practice Address - Country:US
Practice Address - Phone:980-254-1778
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-27
Last Update Date:2019-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC3747A0650X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider