Provider Demographics
NPI:1255673893
Name:WILSON, SALLY (FNP)
Entity Type:Individual
Prefix:
First Name:SALLY
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4456 DAWES AVE
Mailing Address - Street 2:
Mailing Address - City:CULVER CITY
Mailing Address - State:CA
Mailing Address - Zip Code:90230-5124
Mailing Address - Country:US
Mailing Address - Phone:310-319-4503
Mailing Address - Fax:
Practice Address - Street 1:4456 DAWES AVE
Practice Address - Street 2:
Practice Address - City:CULVER CITY
Practice Address - State:CA
Practice Address - Zip Code:90230
Practice Address - Country:US
Practice Address - Phone:310-319-4503
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-21
Last Update Date:2013-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA514467163WW0101X
CA13414363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WW0101XNursing Service ProvidersRegistered NurseWomen's Health Care, Ambulatory