Healthcare Provider Details

I. General information

NPI: 1124965488
Provider Name (Legal Business Name): JULIA GRACE WILSON MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/04/2026
Last Update Date: 05/04/2026
Certification Date: 05/03/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

620 JOHN PAUL JONES CIR
PORTSMOUTH VA
23708-2111
US

IV. Provider business mailing address

810 REDGATE AVE APT 1
NORFOLK VA
23507-1534
US

V. Phone/Fax

Practice location:
  • Phone: 757-953-5000
  • Fax:
Mailing address:
  • Phone: 757-675-1909
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171000000X
TaxonomyMilitary Health Care Provider
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: