Provider Demographics
NPI:1124540984
Name:WILSON, CONNIE N (MED)
Entity Type:Individual
Prefix:
First Name:CONNIE
Middle Name:N
Last Name:WILSON
Suffix:
Gender:F
Credentials:MED
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 1336
Mailing Address - Street 2:
Mailing Address - City:WEST POINT
Mailing Address - State:MS
Mailing Address - Zip Code:39773-1336
Mailing Address - Country:US
Mailing Address - Phone:662-524-4347
Mailing Address - Fax:662-524-4364
Practice Address - Street 1:302 N JACKSON ST
Practice Address - Street 2:
Practice Address - City:STARKVILLE
Practice Address - State:MS
Practice Address - Zip Code:39759-2504
Practice Address - Country:US
Practice Address - Phone:662-323-9318
Practice Address - Fax:662-323-5552
Is Sole Proprietor?:No
Enumeration Date:2017-07-13
Last Update Date:2017-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health