Healthcare Provider Details

I. General information

NPI: 1245291251
Provider Name (Legal Business Name): JODI ANDERSON WILSON NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: JODI ANDERSON REALE NP

II. Dates (important events)

Enumeration Date: 03/29/2006
Last Update Date: 09/16/2024
Certification Date: 09/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

173 MIDDLE ST
LANCASTER NH
03584-3508
US

IV. Provider business mailing address

59 PAGE HILL RD
BERLIN NH
03570-3531
US

V. Phone/Fax

Practice location:
  • Phone: 603-788-4911
  • Fax: 603-326-5831
Mailing address:
  • Phone: 603-788-5764
  • Fax: 603-326-5831

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number180210
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License NumberRN180210
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: