MEDICARE: VITA J WILSON CFNP

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	363LF0000X	Family Nurse Practitioner	R671908	MS

General Provider Information

NPI Number	:	1912087669
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	VITA J WILSON CFNP

Provider Business Mailing Address
First Line	:	1452 TALLY HO CIR
Second Line	:
City	:	GULFPORT
State	:	MS
Zip	:	39507-4229
Country	:	US
Telephone Number	:	228-896-7568
Fax Number	:

Provider Business Practice Location Address
First Line	:	250 BEAUVOIR RD STE 5
Second Line	:
City	:	BILOXI
State	:	MS
Zip	:	39531-4026
Country	:	US
Telephone Number	:	228-388-2599
Fax Number	:

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

Provider Enumeration Date	:	10/17/2006
Last Update Date	:	07/08/2007

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