Provider Demographics
NPI:1467605089
Name:WILSON, ETHEL A (RD, MS, LDN)
Entity Type:Individual
Prefix:
First Name:ETHEL
Middle Name:A
Last Name:WILSON
Suffix:
Gender:F
Credentials:RD, MS, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11110 MEDICAL CAMPUS RD
Mailing Address - Street 2:SUITE 108
Mailing Address - City:HAGERSTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21742-6700
Mailing Address - Country:US
Mailing Address - Phone:301-714-4041
Mailing Address - Fax:301-714-4351
Practice Address - Street 1:11110 MEDICAL CAMPUS RD
Practice Address - Street 2:SUITE 108
Practice Address - City:HAGERSTOWN
Practice Address - State:MD
Practice Address - Zip Code:21742-6700
Practice Address - Country:US
Practice Address - Phone:301-714-4041
Practice Address - Fax:301-714-4351
Is Sole Proprietor?:No
Enumeration Date:2008-10-28
Last Update Date:2009-11-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDD01601133NN1002X, 133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education
No133V00000XDietary & Nutritional Service ProvidersDietitian, Registered