Healthcare Provider Details

I. General information

NPI: 1255370524
Provider Name (Legal Business Name): DENISE V WILSON CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/05/2006
Last Update Date: 07/12/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

957 NATIONAL HWY STE 3
LAVALE MD
21502-7356
US

IV. Provider business mailing address

957 NATIONAL HIGHWAY STE 3
LAVALE MD
21502
US

V. Phone/Fax

Practice location:
  • Phone: 240-362-7128
  • Fax: 240-362-7129
Mailing address:
  • Phone: 240-362-7128
  • Fax: 240-362-7129

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberR137604
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: