Healthcare Provider Details

I. General information

NPI: 1417970682
Provider Name (Legal Business Name): LORI B WILSON RM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/26/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2211 N WEBER ST
COLORADO SPRINGS CO
80907-6946
US

IV. Provider business mailing address

2011 FIELDCREST DR
COLORADO SPRINGS CO
80921-4008
US

V. Phone/Fax

Practice location:
  • Phone: 719-460-6463
  • Fax:
Mailing address:
  • Phone: 719-460-6463
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175M00000X
TaxonomyLay Midwife
License Number58
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: