MEDICARE: MRS. NINA MARIE WILSON CNM

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	367A00000X	Advanced Practice Midwife	APRNCNM0019444	OH

General Provider Information

NPI Number	:	1962479709
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. NINA MARIE WILSON CNM

Provider Business Mailing Address
First Line	:	100 LILLIAN GISH BLVD SW STE 201
Second Line	:
City	:	MASSILLON
State	:	OH
Zip	:	44647-6500
Country	:	US
Telephone Number	:	716-631-8212
Fax Number	:	716-631-8710

Provider Business Practice Location Address
First Line	:	100 LILLIAN GISH BLVD SW STE 201
Second Line	:
City	:	MASSILLON
State	:	OH
Zip	:	44647-6500
Country	:	US
Telephone Number	:	330-809-0460
Fax Number	:	330-809-0560

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

Provider Enumeration Date	:	03/01/2006
Last Update Date	:	08/19/2020

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