Healthcare Provider Details

I. General information

NPI: 1861868275
Provider Name (Legal Business Name): MONICA WILSON FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: MONICA RUSSELL

II. Dates (important events)

Enumeration Date: 08/19/2015
Last Update Date: 08/19/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2960 SACRAMENTO ST
BERKELEY CA
94702-2510
US

IV. Provider business mailing address

700 ADELINE ST
OAKLAND CA
94607-2608
US

V. Phone/Fax

Practice location:
  • Phone: 510-549-3166
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberNP95002809
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: