MEDICARE: NINA WILSON

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YP1600X	Pastoral Counselor
2	174H00000X	Health Educator

General Provider Information

NPI Number	:	1083276497
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NINA WILSON

Provider Business Mailing Address
First Line	:	PO BOX 35
Second Line	:
City	:	STOCKBRIDGE
State	:	GA
Zip	:	30281-0035
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1015 S 4TH ST
Second Line	:
City	:	LOUISVILLE
State	:	KY
Zip	:	40203-3207
Country	:	US
Telephone Number	:	502-708-8227
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/05/2019
Last Update Date	:	07/05/2019

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Directions to “ NINA WILSON ” Practice Location

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