Healthcare Provider Details

I. General information

NPI: 1932879269
Provider Name (Legal Business Name): HIROKO WILSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/17/2021
Last Update Date: 09/17/2021
Certification Date: 09/02/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

409 FARRELL ST APT 410
SOUTH BURLINGTON VT
05403-4427
US

IV. Provider business mailing address

409 FARRELL ST APT 410
SOUTH BURLINGTON VT
05403-4427
US

V. Phone/Fax

Practice location:
  • Phone: 802-578-7376
  • Fax:
Mailing address:
  • Phone: 802-578-7376
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WH0200X
TaxonomyHome Health Registered Nurse
License Number026.0139210
License Number StateVT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: