Provider Demographics
NPI:1467896753
Name:WILSON, MARY JANE LIM (FNP)
Entity Type:Individual
Prefix:MRS
First Name:MARY JANE
Middle Name:LIM
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 1:1705 ASPEN VILLAGE WAY
Mailing Address - Street 2:
Mailing Address - City:WEST COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91791-3105
Mailing Address - Country:US
Mailing Address - Phone:626-918-3042
Mailing Address - Fax:
Practice Address - Street 1:1705 ASPEN VILLAGE WAY
Practice Address - Street 2:
Practice Address - City:WEST COVINA
Practice Address - State:CA
Practice Address - Zip Code:91791-3105
Practice Address - Country:US
Practice Address - Phone:626-918-3042
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-17
Last Update Date:2013-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA22483363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily