Healthcare Provider Details

I. General information

NPI: 1154528685
Provider Name (Legal Business Name): ELIZABETH ROBIN WILSON C.N.M.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/28/2007
Last Update Date: 05/14/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

916 S BROAD ST
THOMASVILLE GA
31792-6113
US

IV. Provider business mailing address

360 COLLEGE ST
BLAKELY GA
39823-2554
US

V. Phone/Fax

Practice location:
  • Phone: 229-226-8800
  • Fax: 229-226-1660
Mailing address:
  • Phone: 229-723-2660
  • Fax: 229-723-5969

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License NumberRN123110
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: