Healthcare Provider Details

I. General information

NPI: 1871045807
Provider Name (Legal Business Name): GRISELDA WILSON RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/25/2016
Last Update Date: 10/25/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 S COUNTY LINE DR
CHAPARRAL NM
88081-7869
US

IV. Provider business mailing address

PO DRAWER 70
ANTHONY NM
88021
US

V. Phone/Fax

Practice location:
  • Phone: 575-824-3156
  • Fax:
Mailing address:
  • Phone: 575-882-6101
  • Fax: 575-882-6926

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WS0200X
TaxonomySchool Registered Nurse
License Number906061
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: