Provider Demographics
NPI:1740253319
Name:WILSON, ANGELA COLE (ANP-BC, PMHNP-BC)
Entity type:Individual
Prefix:
First Name:ANGELA
Middle Name:COLE
Last Name:WILSON
Suffix:
Gender:F
Credentials:ANP-BC, PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:284 EXECUTIVE PARK DR STE 100
Mailing Address - Street 2:
Mailing Address - City:CONCORD
Mailing Address - State:NC
Mailing Address - Zip Code:28025-1833
Mailing Address - Country:US
Mailing Address - Phone:704-939-1100
Mailing Address - Fax:704-939-1173
Practice Address - Street 1:284 EXECUTIVE PARK DR STE 100
Practice Address - Street 2:
Practice Address - City:CONCORD
Practice Address - State:NC
Practice Address - Zip Code:28025-1833
Practice Address - Country:US
Practice Address - Phone:707-939-1100
Practice Address - Fax:704-939-1173
Is Sole Proprietor?:No
Enumeration Date:2006-02-13
Last Update Date:2024-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC900452363LP0808X, 364SA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No364SA2200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7003724Medicaid
NC2592326CMedicare PIN
NCQ36916Medicare UPIN
NC7003724Medicaid