1972673648 NPI number — DANNYLU J WILSON NP

Table of content: DANNYLU J WILSON NP (NPI 1972673648)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1972673648 NPI number — DANNYLU J WILSON NP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WILSON
Provider First Name:
DANNYLU
Provider Middle Name:
J
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
NP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1972673648
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/28/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
435 AIRPORT BLVD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
PENSACOLA
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32503-7847
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
850-435-7448
Provider Business Mailing Address Fax Number:
850-435-3156

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
435 AIRPORT BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
PENSACOLA
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32503-7847
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
850-435-7448
Provider Business Practice Location Address Fax Number:
850-435-3156
Provider Enumeration Date:
11/09/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  5510 , registered in the state of TN ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1507471 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 3732438 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 4135398 . This is a "BCBST" identifier , issued by the state of ( TN ) . This identifiers is of the category "OTHER".
  • Identifier: 4193459 . This is a "BCBS" identifier . This identifiers is of the category "OTHER".
  • Identifier: 3346726 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 3710089 , issued by the state of ( TN ) . This identifiers is of the category "MEDICAID".
  • Identifier: 101852700 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".




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