Healthcare Provider Details

I. General information

NPI: 1063431708
Provider Name (Legal Business Name): MARY F WILSON NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/19/2006
Last Update Date: 12/08/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14211 WHITE CREEK AVE NE
CEDAR SPRINGS MI
49319-8168
US

IV. Provider business mailing address

5900 BYRON CENTER AVE SW MEDICAL ADMINISTRATION
WYOMING MI
49519-9606
US

V. Phone/Fax

Practice location:
  • Phone: 616-252-6320
  • Fax: 616-252-6360
Mailing address:
  • Phone: 616-252-3243
  • Fax: 616-252-0260

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number470404192436
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number4704192436
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: