Provider Demographics
NPI:1801948997
Name:PACKHEISER, MARIGOLD (NP)
Entity type:Individual
Prefix:
First Name:MARIGOLD
Middle Name:
Last Name:PACKHEISER
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 1:5500 N WARRENDALE CT
Mailing Address - Street 2:
Mailing Address - City:WILMINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:28409-4015
Mailing Address - Country:US
Mailing Address - Phone:336-908-3462
Mailing Address - Fax:
Practice Address - Street 1:2334 S 41ST ST
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:NC
Practice Address - Zip Code:28403-5502
Practice Address - Country:US
Practice Address - Phone:336-908-3462
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-17
Last Update Date:2017-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC600076363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology