Provider Demographics
NPI:1528379732
Name:SOLIVAN WILSON, RAQUEL SHELLY (IDMT)
Entity Type:Individual
Prefix:
First Name:RAQUEL
Middle Name:SHELLY
Last Name:SOLIVAN WILSON
Suffix:
Gender:F
Credentials:IDMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23 MEDICAL GROUP/SGPF 3278 MITCHELL BLVD BLDG 900
Mailing Address - Street 2:
Mailing Address - City:MOODY AFB
Mailing Address - State:GA
Mailing Address - Zip Code:31699-0001
Mailing Address - Country:US
Mailing Address - Phone:229-257-4685
Mailing Address - Fax:229-257-3242
Practice Address - Street 1:23 MEDICAL GROUP/SGPF 3278 MITCHELL BLVD BLD 900
Practice Address - Street 2:
Practice Address - City:MOODY AFB
Practice Address - State:GA
Practice Address - Zip Code:31699-8273
Practice Address - Country:US
Practice Address - Phone:229-257-4685
Practice Address - Fax:229-257-3242
Is Sole Proprietor?:No
Enumeration Date:2010-06-23
Last Update Date:2023-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1002XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Corpsman
Yes1710I1003XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Medical Technicians