Healthcare Provider Details

I. General information

NPI: 1881907103
Provider Name (Legal Business Name): GLORIA S WILSON RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/15/2010
Last Update Date: 07/15/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1663 E 17TH ST
BROOKLYN NY
11229-1259
US

IV. Provider business mailing address

1431 WHITE PLAINS RD
BRONX NY
10462-4103
US

V. Phone/Fax

Practice location:
  • Phone: 718-998-0200
  • Fax: 719-339-4171
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WS0200X
TaxonomySchool Registered Nurse
License Number442354-1
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: