Provider Demographics
NPI:1063234037
Name:HARRY, NICOLE WIRTH (PMHNP-BC)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:WIRTH
Last Name:HARRY
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:HENSEY
Other - Last Name:WIRTH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:112 W COLONNADE DR
Mailing Address - Street 2:
Mailing Address - City:HAMPSTEAD
Mailing Address - State:NC
Mailing Address - Zip Code:28443-3752
Mailing Address - Country:US
Mailing Address - Phone:910-548-3022
Mailing Address - Fax:
Practice Address - Street 1:1703 COUNTRY CLUB RD
Practice Address - Street 2:SUITE 204
Practice Address - City:JACKSONVILLE
Practice Address - State:NC
Practice Address - Zip Code:28546
Practice Address - Country:US
Practice Address - Phone:910-347-3010
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-10-30
Last Update Date:2024-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5021083363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health