Provider Demographics
NPI:1144242256
Name:RUSHTON, WANDA ELLIOTT (FNP-C)
Entity type:Individual
Prefix:
First Name:WANDA
Middle Name:ELLIOTT
Last Name:RUSHTON
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:PO BOX 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:704-384-9672
Mailing Address - Fax:
Practice Address - Street 1:1400 WESTGATE CENTER DRIVE
Practice Address - Street 2:SUITE 130
Practice Address - City:WINSTON SALEM
Practice Address - State:NC
Practice Address - Zip Code:27103-3104
Practice Address - Country:US
Practice Address - Phone:336-718-7500
Practice Address - Fax:336-659-8704
Is Sole Proprietor?:No
Enumeration Date:2006-07-25
Last Update Date:2020-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC200868363L00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
500021736Medicare PIN
NCS72472Medicare UPIN
2591610Medicare ID - Type Unspecified