Provider Demographics
NPI:1982620423
Name:WACHOWIAK, WILMA LYNNE (APRN, BC)
Entity Type:Individual
Prefix:MS
First Name:WILMA
Middle Name:LYNNE
Last Name:WACHOWIAK
Suffix:
Gender:F
Credentials:APRN, BC
Other - Prefix:MS
Other - First Name:WILLIE
Other - Middle Name:LYNNE
Other - Last Name:WACHOWIAK
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:RN, FNP-C, MSN
Mailing Address - Street 1:9025 NOLESGATE RD
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28215-9742
Mailing Address - Country:US
Mailing Address - Phone:704-536-6288
Mailing Address - Fax:
Practice Address - Street 1:3344 PRESSON RD
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:NC
Practice Address - Zip Code:28112-9140
Practice Address - Country:US
Practice Address - Phone:704-292-2749
Practice Address - Fax:704-292-2721
Is Sole Proprietor?:No
Enumeration Date:2006-07-15
Last Update Date:2009-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC49418363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCNPA699Medicaid
SCNPA699Medicaid