Provider Demographics
NPI:1275509580
Name:WILSON, JOHNNIE S
Entity Type:Individual
Prefix:MRS
First Name:JOHNNIE
Middle Name:S
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 1:3406 COLLEGE ST
Mailing Address - Street 2:ATTN: LEGAL DEPT.
Mailing Address - City:BEAUMONT
Mailing Address - State:TX
Mailing Address - Zip Code:77701-4612
Mailing Address - Country:US
Mailing Address - Phone:409-813-2332
Mailing Address - Fax:
Practice Address - Street 1:207 E COURT ST
Practice Address - Street 2:
Practice Address - City:NEWTON
Practice Address - State:TX
Practice Address - Zip Code:75966-3203
Practice Address - Country:US
Practice Address - Phone:409-379-2647
Practice Address - Fax:409-379-2349
Is Sole Proprietor?:No
Enumeration Date:2006-02-27
Last Update Date:2013-06-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX535111363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX535111OtherRN LICENSE
TX564467Medicare UPIN
TX535111OtherRN LICENSE