Provider Demographics
NPI:1144591348
Name:WILSON, NAN (MS, CCC-SLP)
Entity Type:Individual
Prefix:MRS
First Name:NAN
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:MS, CCC-SLP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:56 SERENE MEADOWS DR
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39402-8773
Mailing Address - Country:US
Mailing Address - Phone:601-310-7676
Mailing Address - Fax:
Practice Address - Street 1:285 HOLMES PITTMAN RD
Practice Address - Street 2:
Practice Address - City:FOXWORTH
Practice Address - State:MS
Practice Address - Zip Code:39483-3166
Practice Address - Country:US
Practice Address - Phone:601-736-3111
Practice Address - Fax:601-444-5036
Is Sole Proprietor?:Yes
Enumeration Date:2012-01-19
Last Update Date:2012-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSS2393235Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes235Z00000XSpeech, Language and Hearing Service ProvidersSpeech-Language Pathologist