Healthcare Provider Details

I. General information

NPI: 1275509580
Provider Name (Legal Business Name): MRS. JOHNNIE S WILSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/27/2006
Last Update Date: 06/27/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

207 E COURT ST
NEWTON TX
75966-3203
US

IV. Provider business mailing address

3406 COLLEGE ST ATTN: LEGAL DEPT.
BEAUMONT TX
77701-4612
US

V. Phone/Fax

Practice location:
  • Phone: 409-379-2647
  • Fax: 409-379-2349
Mailing address:
  • Phone: 409-813-2332
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number535111
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: