Provider Demographics
NPI:1497789069
Name:WILSON, JULIE M (PHD)
Entity Type:Individual
Prefix:PROF
First Name:JULIE
Middle Name:M
Last Name:WILSON
Suffix:
Gender:F
Credentials:PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:MEMORIAL HOSPITAL OF RHODE ISLAND
Mailing Address - Street 2:111 BREWSTER STREET
Mailing Address - City:PAWTUCKET
Mailing Address - State:RI
Mailing Address - Zip Code:02860
Mailing Address - Country:US
Mailing Address - Phone:401-729-6200
Mailing Address - Fax:401-729-6203
Practice Address - Street 1:111 BREWSTER ST
Practice Address - Street 2:
Practice Address - City:PAWTUCKET
Practice Address - State:RI
Practice Address - Zip Code:02860-4474
Practice Address - Country:US
Practice Address - Phone:401-729-6200
Practice Address - Fax:401-729-6203
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2020-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIPS00582103T00000X, 363L00000X
RIAPRN00315363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
No103T00000XBehavioral Health & Social Service ProvidersPsychologist
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
RI25670-4OtherBLUE CROSS/BLUE SHIELD
RI410199OtherBLUECHIP
RI410199OtherBLUECHIP
RIS65960Medicare UPIN