Healthcare Provider Details

I. General information

NPI: 1811079346
Provider Name (Legal Business Name): JENNIFER M. WILSON CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/20/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

75 FRANCIS STREET BRIGHAM AND WOMEN'S HOSPITAL
BOSTON MA
02115
US

IV. Provider business mailing address

656 E 7TH ST # 2
BOSTON MA
02127-4225
US

V. Phone/Fax

Practice location:
  • Phone: 617-732-5500
  • Fax:
Mailing address:
  • Phone: 617-268-2926
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number210302
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: