Provider Demographics
NPI:1346473030
Name:WILLSON, CAROLE L (CRNP)
Entity Type:Individual
Prefix:
First Name:CAROLE
Middle Name:L
Last Name:WILLSON
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:225 PENN AVE
Mailing Address - Street 2:
Mailing Address - City:SCRANTON
Mailing Address - State:PA
Mailing Address - Zip Code:18503-1921
Mailing Address - Country:US
Mailing Address - Phone:570-342-7864
Mailing Address - Fax:570-207-7678
Practice Address - Street 1:503 SUNSET DR
Practice Address - Street 2:
Practice Address - City:OLYPHANT
Practice Address - State:PA
Practice Address - Zip Code:18447-1323
Practice Address - Country:US
Practice Address - Phone:570-342-7864
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-08-27
Last Update Date:2014-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP010401363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily