Provider Demographics
NPI:1417029133
Name:WILSON, TINY BENITA (FNP)
Entity Type:Individual
Prefix:MS
First Name:TINY
Middle Name:BENITA
Last Name:WILSON
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2890 GEORGIA HIGHWAY 212 SW STE A360
Mailing Address - Street 2:
Mailing Address - City:CONYERS
Mailing Address - State:GA
Mailing Address - Zip Code:30094-3363
Mailing Address - Country:US
Mailing Address - Phone:770-601-6892
Mailing Address - Fax:
Practice Address - Street 1:2890 GEORGIA HIGHWAY 212 SW STE A360
Practice Address - Street 2:
Practice Address - City:CONYERS
Practice Address - State:GA
Practice Address - Zip Code:30094
Practice Address - Country:US
Practice Address - Phone:770-601-6892
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-15
Last Update Date:2018-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN135948NP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily