Healthcare Provider Details

I. General information

NPI: 1366837775
Provider Name (Legal Business Name): MR. GERREN CURTIS WILSON
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/02/2015
Last Update Date: 09/20/2022
Certification Date: 09/20/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5001 WESTBANK EXPY STE 100
MARRERO LA
70072-2954
US

IV. Provider business mailing address

3616 S I 10 SERVICE RD W STE 100
METAIRIE LA
70001-1874
US

V. Phone/Fax

Practice location:
  • Phone: 504-349-8708
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code364SP0808X
TaxonomyPsychiatric/Mental Health Clinical Nurse Specialist
License NumberAP08247
License Number StateLA
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAP08247
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: