Healthcare Provider Details

I. General information

NPI: 1679042790
Provider Name (Legal Business Name): PATTY R. WILSON CRNP-PMH, PHD
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/19/2018
Last Update Date: 01/11/2024
Certification Date: 01/11/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 N CHARLES ST STE 4R
BALTIMORE MD
21201-5318
US

IV. Provider business mailing address

525 N WOLFE ST
BALTIMORE MD
21205-2110
US

V. Phone/Fax

Practice location:
  • Phone: 240-304-3327
  • Fax:
Mailing address:
  • Phone: 410-929-0104
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberR122302
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: