Provider Demographics
NPI:1851960173
Name:WILMOTH, MARY ANN (PMHNP - BC, FNP-BC)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ANN
Last Name:WILMOTH
Suffix:
Gender:F
Credentials:PMHNP - BC, FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:499 S CENTER CHURCH RD
Mailing Address - Street 2:
Mailing Address - City:THURMOND
Mailing Address - State:NC
Mailing Address - Zip Code:28683-9683
Mailing Address - Country:US
Mailing Address - Phone:828-406-6055
Mailing Address - Fax:
Practice Address - Street 1:791 JONESTOWN RD
Practice Address - Street 2:
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-1252
Practice Address - Country:US
Practice Address - Phone:336-716-4551
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-06-21
Last Update Date:2021-06-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2723702084P0804X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2084P0804XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyChild & Adolescent PsychiatryGroup - Multi-Specialty