Provider Demographics
NPI:1437420452
Name:WILSON, GLORIA J (CNP)
Entity Type:Individual
Prefix:
First Name:GLORIA
Middle Name:J
Last Name:WILSON
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5964 GOLF CLUB LN
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD TOWNSHIP
Mailing Address - State:OH
Mailing Address - Zip Code:45011-8224
Mailing Address - Country:US
Mailing Address - Phone:513-893-1100
Mailing Address - Fax:513-893-1128
Practice Address - Street 1:5964 GOLF CLUB LN
Practice Address - Street 2:
Practice Address - City:FAIRFIELD TOWNSHIP
Practice Address - State:OH
Practice Address - Zip Code:45011-8224
Practice Address - Country:US
Practice Address - Phone:513-893-1100
Practice Address - Fax:513-893-1128
Is Sole Proprietor?:No
Enumeration Date:2012-01-23
Last Update Date:2020-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCOA12816NP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0060292Medicaid
OHH067092Medicare PIN