Provider Demographics
NPI:1225250780
Name:WILSON, DODDIE LOUISE (NP)
Entity Type:Individual
Prefix:MS
First Name:DODDIE
Middle Name:LOUISE
Last Name:WILSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:MS
Other - First Name:DORA
Other - Middle Name:LOUISE
Other - Last Name:WILSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:NP
Mailing Address - Street 1:5705 SALOMA AVE
Mailing Address - Street 2:
Mailing Address - City:VAN NUYS
Mailing Address - State:CA
Mailing Address - Zip Code:91411
Mailing Address - Country:US
Mailing Address - Phone:818-517-4755
Mailing Address - Fax:
Practice Address - Street 1:2701 W. ALAMEDA AVE
Practice Address - Street 2:SUITE 607
Practice Address - City:BURBANK
Practice Address - State:CA
Practice Address - Zip Code:91505
Practice Address - Country:US
Practice Address - Phone:818-842-1410
Practice Address - Fax:818-842-1408
Is Sole Proprietor?:No
Enumeration Date:2007-05-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA15475363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health