Provider Demographics
NPI:1376932707
Name:WILSON, MARY
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
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 1:119 WHISPERING WOODS LN
Mailing Address - Street 2:
Mailing Address - City:ALEXANDRIA
Mailing Address - State:KY
Mailing Address - Zip Code:41001-9226
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:119 WHISPERING WOODS LN
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:KY
Practice Address - Zip Code:41001-9226
Practice Address - Country:US
Practice Address - Phone:859-468-5513
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-01-22
Last Update Date:2015-01-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator