Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363LW0102X | Nurse Practitioner - Women's Health | SP011865 | PA |
NPI | 1053689026 |
---|---|
Provider Name | Victoria Lynn Wilson |
First Address | Philadelphia, PA 19104-4206 |
Second Address | Philadelphia, PA 19104-4206 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 06/12/2011 |
Last Update Date | 21/02/2012 |