Provider Demographics
NPI:1558697862
Name:WILSON, NICOLE CELESTE
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:CELESTE
Last Name:WILSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1613 WOODBROOK LN
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19150-1021
Mailing Address - Country:US
Mailing Address - Phone:267-974-2372
Mailing Address - Fax:
Practice Address - Street 1:7600 CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19111-2442
Practice Address - Country:US
Practice Address - Phone:215-728-2112
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-10-20
Last Update Date:2009-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PARN309077L367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered