Healthcare Provider Details

I. General information

NPI: 1366951519
Provider Name (Legal Business Name): MRS. PRISCILLA MARIE WILSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/20/2017
Last Update Date: 09/17/2020
Certification Date: 09/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10005 E OSBORN RD
SCOTTSDALE AZ
85256-4019
US

IV. Provider business mailing address

3030 N CENTRAL AVE STE 1001
PHOENIX AZ
85012-2716
US

V. Phone/Fax

Practice location:
  • Phone: 480-362-7400
  • Fax: 480-362-5950
Mailing address:
  • Phone: 602-406-4786
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP10609
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: