Healthcare Provider Details

I. General information

NPI: 1467750083
Provider Name (Legal Business Name): LORETTA KATHERINE WILSON PMHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/06/2011
Last Update Date: 03/06/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

52 DORE ST
SAN FRANCISCO CA
94103-3828
US

IV. Provider business mailing address

368 FELL ST
SAN FRANCISCO CA
94102-5144
US

V. Phone/Fax

Practice location:
  • Phone: 415-553-3100
  • Fax: 415-553-3119
Mailing address:
  • Phone: 415-861-0828
  • Fax: 415-861-0257

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code364SP0808X
TaxonomyPsychiatric/Mental Health Clinical Nurse Specialist
License Number787739
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: