Provider Demographics
NPI:1518191444
Name:WILSON, MARY ELLEN (CNS-BC)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:ELLEN
Last Name:WILSON
Suffix:
Gender:F
Credentials:CNS-BC
Other - Prefix:
Other - First Name:MARY
Other - Middle Name:ELLEN
Other - Last Name:COBB
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:3350 EXECUTIVE DR
Mailing Address - Street 2:SUITE 100
Mailing Address - City:SAN ANGELO
Mailing Address - State:TX
Mailing Address - Zip Code:76904-6878
Mailing Address - Country:US
Mailing Address - Phone:325-245-4501
Mailing Address - Fax:325-245-4508
Practice Address - Street 1:3350 EXECUTIVE DR
Practice Address - Street 2:SUITE 100
Practice Address - City:SAN ANGELO
Practice Address - State:TX
Practice Address - Zip Code:76904-6878
Practice Address - Country:US
Practice Address - Phone:325-245-4501
Practice Address - Fax:325-245-4508
Is Sole Proprietor?:No
Enumeration Date:2009-05-06
Last Update Date:2014-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX697182364SA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SA2200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistAdult Health