Healthcare Provider Details

I. General information

NPI: 1881186120
Provider Name (Legal Business Name): NICHOLE WILSON NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/02/2018
Last Update Date: 01/10/2024
Certification Date: 01/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

355 PRAIRIE AVE
PROVIDENCE RI
02905-1928
US

IV. Provider business mailing address

375 ALLENS AVE
PROVIDENCE RI
02905-5010
US

V. Phone/Fax

Practice location:
  • Phone: 401-444-0570
  • Fax: 401-444-0427
Mailing address:
  • Phone: 401-444-0400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberAPRN03871
License Number StateRI
# 2
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License NumberF308344
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: