Healthcare Provider Details

I. General information

NPI: 1982080461
Provider Name (Legal Business Name): SHELLEY WILSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/06/2015
Last Update Date: 08/06/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 WALNUT ST STE A
POCOMOKE CITY MD
21851-1501
US

IV. Provider business mailing address

PO BOX 249
SNOW HILL MD
21863-0249
US

V. Phone/Fax

Practice location:
  • Phone: 410-957-2005
  • Fax: 410-957-2417
Mailing address:
  • Phone: 410-632-1100
  • Fax: 410-632-2476

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC1500X
TaxonomyCommunity Health Registered Nurse
License NumberL1-361510
License Number StateDE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: