Provider Demographics
NPI:1477739035
Name:WILSON, ANGELA ANNETTE (MNA, CRNA)
Entity Type:Individual
Prefix:
First Name:ANGELA
Middle Name:ANNETTE
Last Name:WILSON
Suffix:
Gender:F
Credentials:MNA, CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:377 SOUTHFORK DR
Mailing Address - Street 2:
Mailing Address - City:FLEETWOOD
Mailing Address - State:NC
Mailing Address - Zip Code:28626-9288
Mailing Address - Country:US
Mailing Address - Phone:336-977-3340
Mailing Address - Fax:
Practice Address - Street 1:600 HOSPITAL DR
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:NC
Practice Address - Zip Code:28112-6000
Practice Address - Country:US
Practice Address - Phone:980-993-3100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-01-14
Last Update Date:2023-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCAPN 3476367500000X
NC3895367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCAN1638Medicaid