Healthcare Provider Details

I. General information

NPI: 1922215474
Provider Name (Legal Business Name): MRS. LORI M WILSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/16/2007
Last Update Date: 11/01/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7801 ACADEMY NE BLDG 2 SUITE 200
ALBUQUERQUE NM
87109
US

IV. Provider business mailing address

3236 WYOMING BLVD NE APT 11B
ALBUQUERQUE NM
87111-9443
US

V. Phone/Fax

Practice location:
  • Phone: 505-273-6300
  • Fax:
Mailing address:
  • Phone: 505-410-2391
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code246RH0600X
TaxonomyHistology Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: