Healthcare Provider Details

I. General information

NPI: 1972773620
Provider Name (Legal Business Name): LAURIE DODGE WILSON RN, ANP-BC, GNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LAURIE FLINT DODGE APRN, ANP, GNP, BC

II. Dates (important events)

Enumeration Date: 03/10/2008
Last Update Date: 03/10/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2150 PENNSYLVANIA AVE NW
WASHINGTON DC
20037-3201
US

IV. Provider business mailing address

2150 PENNSYLVANIA AVE NW #5-411
WASHINGTON DC
20037-3201
US

V. Phone/Fax

Practice location:
  • Phone: 202-741-3333
  • Fax: 202-741-2791
Mailing address:
  • Phone: 202-742-3398
  • Fax: 202-741-3396

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberRN1013020
License Number StateDC
# 2
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License NumberRN1013020
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: