Provider Demographics
NPI:1174043491
Name:WILSON, MARJORIE (NP)
Entity Type:Individual
Prefix:MRS
First Name:MARJORIE
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:56 ELIZABETH ST
Mailing Address - Street 2:
Mailing Address - City:STATEN ISLAND
Mailing Address - State:NY
Mailing Address - Zip Code:10310-1934
Mailing Address - Country:US
Mailing Address - Phone:646-229-0941
Mailing Address - Fax:
Practice Address - Street 1:56 ELIZABETH STREET
Practice Address - Street 2:
Practice Address - City:STATEN ISLAND
Practice Address - State:NY
Practice Address - Zip Code:10310
Practice Address - Country:US
Practice Address - Phone:646-229-0941
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-27
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF307602363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health