Provider Demographics
NPI:1215663737
Name:WILSON, MACKENZIE LESHA (FNP-C)
Entity type:Individual
Prefix:
First Name:MACKENZIE
Middle Name:LESHA
Last Name:WILSON
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1010 TROY ST W
Mailing Address - Street 2:
Mailing Address - City:AHOSKIE
Mailing Address - State:NC
Mailing Address - Zip Code:27910-2146
Mailing Address - Country:US
Mailing Address - Phone:252-862-5590
Mailing Address - Fax:
Practice Address - Street 1:120 HEALTH CENTER DR
Practice Address - Street 2:
Practice Address - City:AHOSKIE
Practice Address - State:NC
Practice Address - Zip Code:27910-8161
Practice Address - Country:US
Practice Address - Phone:252-332-3548
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-27
Last Update Date:2022-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC5016604207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine