Healthcare Provider Details

I. General information

NPI: 1003111444
Provider Name (Legal Business Name): LUCY W WILSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/16/2011
Last Update Date: 01/16/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

781 SALISBURY ST
WORCESTER MA
01609-1124
US

IV. Provider business mailing address

781 SALISBURY ST
WORCESTER MA
01609-1124
US

V. Phone/Fax

Practice location:
  • Phone: 508-753-8402
  • Fax: 508-363-0885
Mailing address:
  • Phone: 508-753-8402
  • Fax: 508-363-0885

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN259030
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: