Provider Demographics
NPI:1467989111
Name:WILSON, ELIZABETH
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1216 GRANBY ST STE 7
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23510-2622
Mailing Address - Country:US
Mailing Address - Phone:757-627-6600
Mailing Address - Fax:757-627-6604
Practice Address - Street 1:1216 GRANBY ST STE 7
Practice Address - Street 2:
Practice Address - City:NORFOLK
Practice Address - State:VA
Practice Address - Zip Code:23510-2622
Practice Address - Country:US
Practice Address - Phone:757-627-6600
Practice Address - Fax:757-627-6604
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-12
Last Update Date:2017-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1497133870Medicaid