Provider Demographics
NPI:1114195476
Name:WILSON, MALLORY A (CRNA)
Entity Type:Individual
Prefix:
First Name:MALLORY
Middle Name:A
Last Name:WILSON
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 55905
Mailing Address - Street 2:
Mailing Address - City:BIRMINGHAM
Mailing Address - State:AL
Mailing Address - Zip Code:35255-5905
Mailing Address - Country:US
Mailing Address - Phone:205-930-7296
Mailing Address - Fax:205-930-7256
Practice Address - Street 1:1201 11TH AVE S
Practice Address - Street 2:
Practice Address - City:BIRMINGHAM
Practice Address - State:AL
Practice Address - Zip Code:35205-3410
Practice Address - Country:US
Practice Address - Phone:205-930-7296
Practice Address - Fax:205-930-7256
Is Sole Proprietor?:No
Enumeration Date:2008-02-20
Last Update Date:2008-06-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-100306367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL51547667OtherBC BS OF AL
AL1114195476Medicaid
AL510I430117Medicare PIN