Provider Demographics
NPI:1346869062
Name:WILSON, GRACE R (RN)
Entity Type:Individual
Prefix:MRS
First Name:GRACE
Middle Name:R
Last Name:WILSON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 HERBERT ST UNIT B
Mailing Address - Street 2:
Mailing Address - City:LYNN
Mailing Address - State:MA
Mailing Address - Zip Code:01902-3808
Mailing Address - Country:US
Mailing Address - Phone:617-821-4923
Mailing Address - Fax:
Practice Address - Street 1:1 HERBERT ST UNIT B
Practice Address - Street 2:
Practice Address - City:LYNN
Practice Address - State:MA
Practice Address - Zip Code:01902-3808
Practice Address - Country:US
Practice Address - Phone:617-821-4923
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-13
Last Update Date:2020-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN266215163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163W00000XNursing Service ProvidersRegistered NurseGroup - Single Specialty