MEDICARE: JOANNE LOUISE WILSON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163WC0200X	Critical Care Medicine Registered Nurse	690333	CA
2	163WC0200X	Critical Care Medicine Registered Nurse	RN0000197360	TN
3	163WC0200X	Critical Care Medicine Registered Nurse	1658772	CO

General Provider Information

NPI Number	:	1275054025
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOANNE LOUISE WILSON

Provider Business Mailing Address
First Line	:	453 VAN GORDON ST APT 5207
Second Line	:
City	:	LAKEWOOD
State	:	CO
Zip	:	80228-1261
Country	:	US
Telephone Number	:	781-696-3197
Fax Number	:

Provider Business Practice Location Address
First Line	:	453 VAN GORDON ST APT 5207
Second Line	:
City	:	LAKEWOOD
State	:	CO
Zip	:	80228-1261
Country	:	US
Telephone Number	:	781-696-3197
Fax Number	:	781-696-3197

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/02/2017
Last Update Date	:	02/19/2019

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