Provider Demographics
NPI:1386203099
Name:WILSON, GEORGINA-MARIE (APRN)
Entity Type:Individual
Prefix:
First Name:GEORGINA-MARIE
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15253 SW 138TH TER
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33196-5015
Mailing Address - Country:US
Mailing Address - Phone:786-752-5584
Mailing Address - Fax:
Practice Address - Street 1:925 NE 30TH TER STE 202
Practice Address - Street 2:
Practice Address - City:HOMESTEAD
Practice Address - State:FL
Practice Address - Zip Code:33033-7614
Practice Address - Country:US
Practice Address - Phone:305-246-1030
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-07
Last Update Date:2019-06-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11000600363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily