MEDICARE: DEBRA ELIZABETH 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	164W00000X	Licensed Practical Nurse	26NPO4515300	NJ

General Provider Information

NPI Number	:	1235958802
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DEBRA ELIZABETH WILSON

Provider Business Mailing Address
First Line	:	222 CYPRESS AVE APT 1
Second Line	:
City	:	WOODLYNNE
State	:	NJ
Zip	:	08107-2122
Country	:	US
Telephone Number	:	856-375-4246
Fax Number	:

Provider Business Practice Location Address
First Line	:	6103 WESTFIELD AVE
Second Line	:
City	:	PENNSAUKEN
State	:	NJ
Zip	:	08110-1754
Country	:	US
Telephone Number	:	856-486-9097
Fax Number	:

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

Provider Enumeration Date	:	10/09/2024
Last Update Date	:	10/09/2024

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