MEDICARE: MISS ANGELICA WALTON 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	163W00000X	Registered Nurse	2472545	MN

General Provider Information

NPI Number	:	1386267441
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MISS ANGELICA WALTON WILSON

Provider Business Mailing Address
First Line	:	1367 WILLOW ST APT 533
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55403-2598
Country	:	US
Telephone Number	:	504-400-2914
Fax Number	:

Provider Business Practice Location Address
First Line	:	1367 WILLOW ST APT 533
Second Line	:
City	:	MINNEAPOLIS
State	:	MN
Zip	:	55403-2598
Country	:	US
Telephone Number	:	504-400-2914
Fax Number	:

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

Provider Enumeration Date	:	05/24/2020
Last Update Date	:	05/24/2020

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