Healthcare Provider Details

I. General information

NPI: 1427172881
Provider Name (Legal Business Name): BETSY VANCE WILSON R.N.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/19/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

920 E 28TH ST SUITE 620
MINNEAPOLIS MN
55407-1139
US

IV. Provider business mailing address

3107 W OWASSO BLVD
ROSEVILLE MN
55113-2167
US

V. Phone/Fax

Practice location:
  • Phone: 612-863-7065
  • Fax: 612-863-6515
Mailing address:
  • Phone: 651-415-0668
  • Fax: 612-863-6515

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WA2000X
TaxonomyAdministrator Registered Nurse
License NumberR 110418-3
License Number StateMN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: