Provider Demographics
NPI:1356303796
Name:WILZACK, CHRISTINE A (PMH-CNS, FNP, PMHNP)
Entity type:Individual
Prefix:
First Name:CHRISTINE
Middle Name:A
Last Name:WILZACK
Suffix:
Gender:F
Credentials:PMH-CNS, FNP, PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:917 OLD BARON DR
Mailing Address - Street 2:
Mailing Address - City:FUQUAY VARINA
Mailing Address - State:NC
Mailing Address - Zip Code:27526-7000
Mailing Address - Country:US
Mailing Address - Phone:302-858-6415
Mailing Address - Fax:
Practice Address - Street 1:190 ROSEWOOD CENTRE DR
Practice Address - Street 2:
Practice Address - City:HOLLY SPRINGS
Practice Address - State:NC
Practice Address - Zip Code:27540-7628
Practice Address - Country:US
Practice Address - Phone:919-851-1527
Practice Address - Fax:919-851-3555
Is Sole Proprietor?:No
Enumeration Date:2006-04-03
Last Update Date:2024-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR104565363LF0000X, 364SP0808X
NC5006513363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No364SP0808XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MD1356303796Medicaid