Provider Demographics
NPI:1942555370
Name:COMPREHENSIVE WELLNESS CENTER OF NORTH CAROLINA, PLLC
Entity Type:Organization
Organization Name:COMPREHENSIVE WELLNESS CENTER OF NORTH CAROLINA, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FAMILY NURSE PRACTITIONER
Authorized Official - Prefix:
Authorized Official - First Name:PAULINE
Authorized Official - Middle Name:
Authorized Official - Last Name:FREDERICK
Authorized Official - Suffix:
Authorized Official - Credentials:FNP
Authorized Official - Phone:910-353-1991
Mailing Address - Street 1:1201 GUM BRANCH RD
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28540-5016
Mailing Address - Country:US
Mailing Address - Phone:910-353-1991
Mailing Address - Fax:910-455-6698
Practice Address - Street 1:1201 GUM BRANCH RD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:NC
Practice Address - Zip Code:28540-5016
Practice Address - Country:US
Practice Address - Phone:910-353-1991
Practice Address - Fax:910-455-6698
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-07-23
Last Update Date:2014-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5004371363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty