Provider Demographics
NPI:1083870265
Name:WILSON, CHARMAINE (MD)
Entity Type:Individual
Prefix:
First Name:CHARMAINE
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9455 HUNTCLIFF TRCE
Mailing Address - Street 2:
Mailing Address - City:SANDY SPRINGS
Mailing Address - State:GA
Mailing Address - Zip Code:30350-2610
Mailing Address - Country:US
Mailing Address - Phone:469-407-1498
Mailing Address - Fax:
Practice Address - Street 1:101 QUARTZ DR STE 103
Practice Address - Street 2:
Practice Address - City:VILLA RICA
Practice Address - State:GA
Practice Address - Zip Code:30180-3255
Practice Address - Country:US
Practice Address - Phone:770-812-3530
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-08-06
Last Update Date:2023-09-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLME1446802084P0800X
MI43011012152084P0800X
GA0680212084P0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry