Provider Demographics
NPI:1083297139
Name:WILSON, ELAINE
Entity Type:Individual
Prefix:
First Name:ELAINE
Middle Name:
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 1:401 WALNUT ST
Mailing Address - Street 2:
Mailing Address - City:WESTERNPORT
Mailing Address - State:MD
Mailing Address - Zip Code:21562-1221
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12 MAPLE HILL AVE STE 1
Practice Address - Street 2:
Practice Address - City:PETERSBURG
Practice Address - State:WV
Practice Address - Zip Code:26847-1547
Practice Address - Country:US
Practice Address - Phone:304-257-9297
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-05
Last Update Date:2021-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider