Provider Demographics
NPI:1386643633
Name:WILSON, MARGUERITE (CNS)
Entity Type:Individual
Prefix:
First Name:MARGUERITE
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:CNS
Other - Prefix:
Other - First Name:MARQUERITE
Other - Middle Name:
Other - Last Name:FABERT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CNS
Mailing Address - Street 1:PO BOX 1067
Mailing Address - Street 2:
Mailing Address - City:MARTINSBURG
Mailing Address - State:WV
Mailing Address - Zip Code:25402-1067
Mailing Address - Country:US
Mailing Address - Phone:304-263-7023
Mailing Address - Fax:304-264-0508
Practice Address - Street 1:99 TAVERN RD
Practice Address - Street 2:
Practice Address - City:MARTINSBURG
Practice Address - State:WV
Practice Address - Zip Code:25401-2890
Practice Address - Country:US
Practice Address - Phone:304-263-7023
Practice Address - Fax:304-264-0508
Is Sole Proprietor?:No
Enumeration Date:2005-07-19
Last Update Date:2013-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV59685163WP0809X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0809XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Adult
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810000513Medicaid
WVP38399Medicare UPIN
WVWI2021961Medicare ID - Type Unspecified