Healthcare Provider Details

I. General information

NPI: 1720202427
Provider Name (Legal Business Name): MARY E WILSON RN, BSN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/12/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2499 KAPIOLANI BLVD #3509
HONOLULU HI
96826-5339
US

IV. Provider business mailing address

2499 KAPIOLANI BLVD #3509
HONOLULU HI
96826-5310
US

V. Phone/Fax

Practice location:
  • Phone: 808-375-7565
  • Fax: 808-942-4001
Mailing address:
  • Phone: 808-375-7565
  • Fax: 808-942-4001

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC0400X
TaxonomyCase Management Registered Nurse
License Number38843
License Number StateHI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: