Provider Demographics
NPI:1194361923
Name:WILMINGTON FAMILY PRACTICE PLLC
Entity type:Organization
Organization Name:WILMINGTON FAMILY PRACTICE PLLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ANNETTE
Authorized Official - Middle Name:
Authorized Official - Last Name:CROUSE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-500-6451
Mailing Address - Street 1:3971 BUSINESS 17 E
Mailing Address - Street 2:
Mailing Address - City:BOLIVIA
Mailing Address - State:NC
Mailing Address - Zip Code:28422-8675
Mailing Address - Country:US
Mailing Address - Phone:910-500-6451
Mailing Address - Fax:910-500-6458
Practice Address - Street 1:3971 BUSINESS 17 E
Practice Address - Street 2:
Practice Address - City:BOLIVIA
Practice Address - State:NC
Practice Address - Zip Code:28422-8675
Practice Address - Country:US
Practice Address - Phone:910-500-6451
Practice Address - Fax:910-500-6458
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-11-27
Last Update Date:2024-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary CareGroup - Multi-Specialty
No207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction MedicineGroup - Multi-Specialty
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC1669918223OtherNPI
NC1821295668Medicaid
NC1992351910Medicaid