Healthcare Provider Details

I. General information

NPI: 1154067593
Provider Name (Legal Business Name): MRS. MADELYN FREEMAN WILSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/09/2022
Last Update Date: 05/09/2022
Certification Date: 05/09/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

604 HIGHWAY 80 W STE R
CLINTON MS
39056-4108
US

IV. Provider business mailing address

223 MAGNOLIA TRL
BRANDON MS
39047-6503
US

V. Phone/Fax

Practice location:
  • Phone: 601-473-2106
  • Fax:
Mailing address:
  • Phone: 769-274-4241
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: