1982690152 NPI number — JENNIFER M WILSON RN, CDE

Table of content: JENNIFER M WILSON RN, CDE (NPI 1982690152)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1982690152 NPI number — JENNIFER M WILSON RN, CDE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WILSON
Provider First Name:
JENNIFER
Provider Middle Name:
M
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
RN, CDE
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:
1982690152
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/08/2007
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
289 COUNTY RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WINDSOR
Provider Business Mailing Address State Name:
VT
Provider Business Mailing Address Postal Code:
05089-9000
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
802-674-7300
Provider Business Mailing Address Fax Number:
802-674-7314

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
289 COUNTY RD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
WINDSOR
Provider Business Practice Location Address State Name:
VT
Provider Business Practice Location Address Postal Code:
05089-9000
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
802-674-7300
Provider Business Practice Location Address Fax Number:
802-674-7314
Provider Enumeration Date:
09/23/2005

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: 163WD0400X , with the licence number:  026-0022105 , registered in the state of VT ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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