Provider Demographics
NPI:1649292830
Name:WILKINS, FONDA MAE (NP)
Entity type:Individual
Prefix:
First Name:FONDA
Middle Name:MAE
Last Name:WILKINS
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:115 BLARNEY DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:SC
Mailing Address - Zip Code:29223-6291
Mailing Address - Country:US
Mailing Address - Phone:803-419-9091
Mailing Address - Fax:803-419-9199
Practice Address - Street 1:115 BLARNEY DR
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:SC
Practice Address - Zip Code:29223-6291
Practice Address - Country:US
Practice Address - Phone:803-419-9091
Practice Address - Fax:803-419-9199
Is Sole Proprietor?:No
Enumeration Date:2006-07-24
Last Update Date:2012-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC2964363LC0200X, 363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No363LC0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerCritical Care Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCNP1257Medicaid
SCP00889659OtherMEDICARE RAILROAD
SCNP1257Medicaid
SCAA15905771Medicare PIN