Provider Demographics
NPI:1528580701
Name:WILSON, CHRISTINE M (RN)
Entity Type:Individual
Prefix:
First Name:CHRISTINE
Middle Name:M
Last Name:WILSON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2500 PUTNAM DRIVE
Mailing Address - Street 2:
Mailing Address - City:EAST MEADOW
Mailing Address - State:NY
Mailing Address - Zip Code:11710
Mailing Address - Country:US
Mailing Address - Phone:516-238-5539
Mailing Address - Fax:
Practice Address - Street 1:2038 RUSSELL ST
Practice Address - Street 2:
Practice Address - City:BELLMORE
Practice Address - State:NY
Practice Address - Zip Code:11710-3224
Practice Address - Country:US
Practice Address - Phone:516-238-5539
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-07-10
Last Update Date:2017-07-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY543328-1163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYPENDINGMedicaid