Provider Demographics
NPI:1720248099
Name:WILSON, STACIE
Entity type:Individual
Prefix:
First Name:STACIE
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 S MAIN ST UNIT B
Mailing Address - Street 2:
Mailing Address - City:WEAVERVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28787-8463
Mailing Address - Country:US
Mailing Address - Phone:828-484-8440
Mailing Address - Fax:828-484-8445
Practice Address - Street 1:10 S MAIN ST UNIT B
Practice Address - Street 2:
Practice Address - City:WEAVERVILLE
Practice Address - State:NC
Practice Address - Zip Code:28787-8463
Practice Address - Country:US
Practice Address - Phone:828-484-8440
Practice Address - Fax:828-484-8445
Is Sole Proprietor?:No
Enumeration Date:2008-06-11
Last Update Date:2010-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC31843747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC6601812Medicaid
NC6601780Medicaid