Healthcare Provider Details

I. General information

NPI: 1255963732
Provider Name (Legal Business Name): VENESSA MARIE WILSON RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/12/2020
Last Update Date: 02/12/2020
Certification Date: 02/12/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1528 US HIGHWAY 395 N STE 100
GARDNERVILLE NV
89410-5226
US

IV. Provider business mailing address

1528 US HIGHWAY 395 N STE 100
GARDNERVILLE NV
89410-5226
US

V. Phone/Fax

Practice location:
  • Phone: 775-782-3671
  • Fax: 775-782-6639
Mailing address:
  • Phone: 775-782-3671
  • Fax: 775-782-6639

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0809X
TaxonomyAdult Psychiatric/Mental Health Registered Nurse
License NumberRN76133
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: