Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363LA2100X | Nurse Practitioner - Acute Care | 2964 | SC |
N | 363LC0200X | Nurse Practitioner - Critical Care Medicine | 2964 | SC |
NPI | 1649292830 |
---|---|
Provider Name | Fonda Mae Wilkins |
First Address | Columbia, SC 29223-6291 |
Second Address | Columbia, SC 29223-6291 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 24/07/2006 |
Last Update Date | 02/03/2012 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
NP1257 | (05) | SC |
P00889659 | MEDICARE RAILROAD (01) | SC |