Provider Demographics
NPI:1093080541
Name:WILSON, ELIZABETH L (PNP)
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:L
Last Name:WILSON
Suffix:
Gender:F
Credentials:PNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:215 12TH ST W
Mailing Address - Street 2:
Mailing Address - City:TIFTON
Mailing Address - State:GA
Mailing Address - Zip Code:31794-3923
Mailing Address - Country:US
Mailing Address - Phone:229-396-5335
Mailing Address - Fax:229-396-5330
Practice Address - Street 1:215 12TH ST W
Practice Address - Street 2:
Practice Address - City:TIFTON
Practice Address - State:GA
Practice Address - Zip Code:31794-3923
Practice Address - Country:US
Practice Address - Phone:229-396-5335
Practice Address - Fax:229-396-5330
Is Sole Proprietor?:No
Enumeration Date:2012-03-16
Last Update Date:2022-10-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN191733363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
GARN191733OtherGA MEDICAL LICENSE