Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363LA2200X | Nurse Practitioner - Adult Health | 902587 | MS |
NPI | 1023507456 |
---|---|
Provider Name | Teresa Wilson |
First Address | Shaw, MS 38773-8710 |
Second Address | Shaw, MS 38773-8710 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 01/05/2018 |
Last Update Date | 01/05/2018 |