Healthcare Provider Details

I. General information

NPI: 1659549673
Provider Name (Legal Business Name): LAUREEN MARIE WILSON LPN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/12/2008
Last Update Date: 02/12/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15 PIPER RD
SCARBOROUGH ME
04074-9473
US

IV. Provider business mailing address

110 MAIN ST #310
SACO ME
04072-3509
US

V. Phone/Fax

Practice location:
  • Phone: 207-883-8700
  • Fax:
Mailing address:
  • Phone: 207-571-4842
  • Fax: 207-571-4842

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License NumberPO11177
License Number StateME
# 2
Primary TaxonomyN
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number010199-22
License Number StateNH
# 3
Primary TaxonomyN
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number34349
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: