Provider Demographics
NPI:1477688588
Name:WILSON, MARY ANN (NP)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:ANN
Last Name:WILSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6390 OLD CHURCH WAY
Mailing Address - Street 2:
Mailing Address - City:REYNOLDSBURG
Mailing Address - State:OH
Mailing Address - Zip Code:43068-4318
Mailing Address - Country:US
Mailing Address - Phone:614-864-6585
Mailing Address - Fax:
Practice Address - Street 1:72 W 3RD AVE
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43201-3209
Practice Address - Country:US
Practice Address - Phone:614-453-9999
Practice Address - Fax:614-453-9998
Is Sole Proprietor?:No
Enumeration Date:2007-02-22
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH07621363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily