Provider Demographics
NPI:1023579042
Name:WILSON, NICOLE L (LPN)
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:L
Last Name:WILSON
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:137 POINT PARK LN
Mailing Address - Street 2:
Mailing Address - City:FRIEDENS
Mailing Address - State:PA
Mailing Address - Zip Code:15541-8337
Mailing Address - Country:US
Mailing Address - Phone:724-840-8412
Mailing Address - Fax:
Practice Address - Street 1:645 RODI RD
Practice Address - Street 2:
Practice Address - City:PITTSBURGH
Practice Address - State:PA
Practice Address - Zip Code:15235-4564
Practice Address - Country:US
Practice Address - Phone:412-723-2775
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-31
Last Update Date:2019-03-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPN281059164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse