Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363LA2200X | Nurse Practitioner - Adult Health | 255482 | MA |
NPI | 1033219282 |
---|---|
Provider Name | Levonne Wilson |
First Address | Springfield, MA 01199-1000 |
Second Address | Springfield, MA 01199-0001 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 25/09/2006 |
Last Update Date | 08/07/2007 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
Q25338 | (02) | MA |