Healthcare Provider Details

I. General information

NPI: 1780380329
Provider Name (Legal Business Name): JUDITH A WILSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/06/2023
Last Update Date: 05/06/2025
Certification Date: 05/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 S ELMORA AVE
ELIZABETH NJ
07202-3100
US

IV. Provider business mailing address

PO BOX 740021
ATLANTA GA
30374-0021
US

V. Phone/Fax

Practice location:
  • Phone: 908-737-5703
  • Fax: 908-325-0075
Mailing address:
  • Phone: 312-733-9730
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number26NJ01437000
License Number StateNJ
# 2
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number26NJ01437000
License Number StateNJ
# 3
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number26NJ01437000
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: