Provider Demographics
NPI:1033551130
Name:WILSON, MOLLIE EVELYN (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:
First Name:MOLLIE
Middle Name:EVELYN
Last Name:WILSON
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5820 W GIRARD AVE
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19131-4850
Mailing Address - Country:US
Mailing Address - Phone:215-205-7149
Mailing Address - Fax:
Practice Address - Street 1:5820 W GIRARD AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19131-4850
Practice Address - Country:US
Practice Address - Phone:215-205-7149
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-18
Last Update Date:2013-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP012970363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care