Provider Demographics
NPI:1275054025
Name:WILSON, JOANNE LOUISE
Entity Type:Individual
Prefix:
First Name:JOANNE
Middle Name:LOUISE
Last Name:WILSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:453 VAN GORDON ST APT 5207
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:CO
Mailing Address - Zip Code:80228-1261
Mailing Address - Country:US
Mailing Address - Phone:781-696-3197
Mailing Address - Fax:
Practice Address - Street 1:453 VAN GORDON ST APT 5207
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:CO
Practice Address - Zip Code:80228-1261
Practice Address - Country:US
Practice Address - Phone:781-696-3197
Practice Address - Fax:781-696-3197
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-02
Last Update Date:2019-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA690333163WC0200X
TNRN0000197360163WC0200X
CO1658772163WC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC0200XNursing Service ProvidersRegistered NurseCritical Care Medicine