Provider Demographics
NPI:1417208810
Name:WILSON, PHOEBE (PNP)
Entity Type:Individual
Prefix:MRS
First Name:PHOEBE
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:PNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1952 LONG GROVE DR
Mailing Address - Street 2:SUITE 202
Mailing Address - City:MT PLEASANT
Mailing Address - State:SC
Mailing Address - Zip Code:29464-7579
Mailing Address - Country:US
Mailing Address - Phone:843-795-8100
Mailing Address - Fax:843-573-2534
Practice Address - Street 1:776 DANIEL ELLIS DR
Practice Address - Street 2:SUITE 2 BUILDING A
Practice Address - City:CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29412-3094
Practice Address - Country:US
Practice Address - Phone:843-795-8100
Practice Address - Fax:843-573-2534
Is Sole Proprietor?:No
Enumeration Date:2012-09-25
Last Update Date:2014-10-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC18030363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics