Healthcare Provider Details

I. General information

NPI: 1235047051
Provider Name (Legal Business Name): THERESA WILSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/01/2026
Last Update Date: 09/01/2026
Certification Date: 09/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 PANCOAST BLVD
DELRAN NJ
08075-1440
US

IV. Provider business mailing address

100 PANCOAST BLVD
DELRAN NJ
08075-1440
US

V. Phone/Fax

Practice location:
  • Phone: 856-229-3543
  • Fax:
Mailing address:
  • Phone: 856-229-3543
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC0400X
TaxonomyCase Management Registered Nurse
License Number26NO11733300
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: