Basic Information
| Provider Information | |||||||||
| NPI: | 1942288790 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | JOHN | ||||||||
| FirstName: | WENDELL | ||||||||
| MiddleName: | CLAVONN | ||||||||
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| Credential: | RN, MSN, FNP-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2001 S MAIN ST | ||||||||
| Address2: | |||||||||
| City: | WAKE FOREST | ||||||||
| State: | NC | ||||||||
| PostalCode: | 275871612 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9195623155 | ||||||||
| FaxNumber: | 9195627401 | ||||||||
| Practice Location | |||||||||
| Address1: | 2001 S MAIN ST | ||||||||
| Address2: | |||||||||
| City: | WAKE FOREST | ||||||||
| State: | NC | ||||||||
| PostalCode: | 275871612 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9195623155 | ||||||||
| FaxNumber: | 9195627401 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/03/2006 | ||||||||
| LastUpdateDate: | 12/01/2018 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 201749 | NC | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 201749 | 01 | NC | NC NURSE PRACTITIONER # | OTHER | MJ0970435 | 01 | NC | DEA CERTIFICATE # | OTHER | 170923 | 01 | NC | NC NURSING LICENSE # | OTHER |