Provider Demographics
NPI:1942288790
Name:JOHN, WENDELL CLAVONN (RN, MSN, FNP-C)
Entity Type:Individual
Prefix:
First Name:WENDELL
Middle Name:CLAVONN
Last Name:JOHN
Suffix:
Gender:M
Credentials:RN, MSN, FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2001 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WAKE FOREST
Mailing Address - State:NC
Mailing Address - Zip Code:27587-1612
Mailing Address - Country:US
Mailing Address - Phone:919-562-3155
Mailing Address - Fax:919-562-7401
Practice Address - Street 1:2001 S MAIN ST
Practice Address - Street 2:
Practice Address - City:WAKE FOREST
Practice Address - State:NC
Practice Address - Zip Code:27587-1612
Practice Address - Country:US
Practice Address - Phone:919-562-3155
Practice Address - Fax:919-562-7401
Is Sole Proprietor?:No
Enumeration Date:2006-01-03
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC201749363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC201749OtherNC NURSE PRACTITIONER #
NC170923OtherNC NURSING LICENSE #
NC170923OtherNC NURSING LICENSE #
NCQ34018Medicare UPIN
NC2592293Medicare PIN