Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363LF0000X | Nurse Practitioner - Family Medicine | RN201447 | GA |
NPI | 1003318833 |
---|---|
Provider Name | Patrice Janice Wilson |
First Address | Fayetteville, GA 30214-7664 |
Second Address | Fayetteville, GA 30214-7664 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 07/03/2018 |
Last Update Date | 07/03/2018 |