Healthcare Provider Details

I. General information

NPI: 1174779367
Provider Name (Legal Business Name): MARIETTA WILSON RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/07/2008
Last Update Date: 08/07/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4230 HARDING RD STE 300 MEDICAL PLAZA EAST
NASHVILLE TN
37205-2158
US

IV. Provider business mailing address

185 SPY GLASS WAY
HENDERSONVILLE TN
37075-8587
US

V. Phone/Fax

Practice location:
  • Phone: 615-783-1269
  • Fax:
Mailing address:
  • Phone: 615-826-6296
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number84068
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: