MEDICARE: MARY WILSON APN, NP

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	363LF0000X	Family Nurse Practitioner	AP136986	TX
2	363LF0000X	Family Nurse Practitioner	21173	TN

General Provider Information

NPI Number	:	1639533953
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARY WILSON APN, NP

Provider Business Mailing Address
First Line	:	6101 BLUE LAGOON DR STE 200
Second Line	:
City	:	MIAMI
State	:	FL
Zip	:	33126-3168
Country	:	US
Telephone Number	:	407-533-6836
Fax Number	:	407-770-0661

Provider Business Practice Location Address
First Line	:	7245 BOULEVARD 26
Second Line	:
City	:	NORTH RICHLAND HILLS
State	:	TX
Zip	:	76180-8605
Country	:	US
Telephone Number	:	850-304-7986
Fax Number	:

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

Provider Enumeration Date	:	04/12/2016
Last Update Date	:	09/19/2025

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