1245584788 NPI number — MRS. CATHERINE MARIE WILSON FNP

Table of content: MRS. CATHERINE MARIE WILSON FNP (NPI 1245584788)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1245584788 NPI number — MRS. CATHERINE MARIE WILSON FNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WILSON
Provider First Name:
CATHERINE
Provider Middle Name:
MARIE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
FNP
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:
1245584788
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/03/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1005 BOULDER DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
GRAY
Provider Business Mailing Address State Name:
GA
Provider Business Mailing Address Postal Code:
31032-6141
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
478-621-2100
Provider Business Mailing Address Fax Number:
478-744-0481

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1005 BOULDER DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
GRAY
Provider Business Practice Location Address State Name:
GA
Provider Business Practice Location Address Postal Code:
31032
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
478-621-2100
Provider Business Practice Location Address Fax Number:
478-744-0481
Provider Enumeration Date:
11/06/2012

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:  RN186801 , registered in the state of GA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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