Healthcare Provider Details

I. General information

NPI: 1932140944
Provider Name (Legal Business Name): MONIQUE S. WILSON APN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/09/2006
Last Update Date: 04/25/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3 COOPER PLZ SUITE 411
CAMDEN NJ
08103-1438
US

IV. Provider business mailing address

1 FEDERAL STREET SUITE SW200
CAMDEN NJ
08103-1155
US

V. Phone/Fax

Practice location:
  • Phone: 856-968-3577
  • Fax: 856-968-8457
Mailing address:
  • Phone: 856-356-4935
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberNN093565
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: