=====================================================
General NPI Number Information
=====================================================
NPI Number | 1548942733
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | WILSON'S HEALTH AND WEIGHT MANAGEMENT LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/07/2023
-----------------------------------------------------
Last Update Date | 08/10/2023
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 807 N HADDON AVE STE 215
-----------------------------------------------------
City | HADDONFIELD
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08033-1749
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 856-400-0064
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 807 N HADDON AVE STE 215
-----------------------------------------------------
City | HADDONFIELD
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08033-1749
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 856-400-0064
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | ELLEN WILSON-TARPEH
-----------------------------------------------------
Credential | DNP, FNP. APN
-----------------------------------------------------
Telephone | 609-477-9354
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QP2300X
-----------------------------------------------------
Taxonomy Name | Primary Care Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------