Provider Demographics
NPI:1003383928
Name:WILSON, CHITRA MAE
Entity Type:Individual
Prefix:MRS
First Name:CHITRA
Middle Name:MAE
Last Name:WILSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3537 DENNY AVE # 347
Mailing Address - Street 2:
Mailing Address - City:PASCAGOULA
Mailing Address - State:MS
Mailing Address - Zip Code:39581-5416
Mailing Address - Country:US
Mailing Address - Phone:228-297-6488
Mailing Address - Fax:
Practice Address - Street 1:3713 JUNIPER ST
Practice Address - Street 2:
Practice Address - City:MOSS POINT
Practice Address - State:MS
Practice Address - Zip Code:39563-6029
Practice Address - Country:US
Practice Address - Phone:228-297-6488
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-29
Last Update Date:2018-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS1157148343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)