MEDICARE: MRS. LORI B WILSON RM

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	175M00000X	Lay Midwife	58	CO

General Provider Information

NPI Number	:	1417970682
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. LORI B WILSON RM

Provider Business Mailing Address
First Line	:	2011 FIELDCREST DR
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80921-4008
Country	:	US
Telephone Number	:	719-460-6463
Fax Number	:

Provider Business Practice Location Address
First Line	:	2211 N WEBER ST
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80907-6946
Country	:	US
Telephone Number	:	719-460-6463
Fax Number	:

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

Provider Enumeration Date	:	07/26/2006
Last Update Date	:	07/08/2007

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