Provider Demographics
NPI:1558704387
Name:WILSON, JOANN
Entity Type:Individual
Prefix:MRS
First Name:JOANN
Middle Name:
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 1:1766 OLD LELAND RD
Mailing Address - Street 2:
Mailing Address - City:GREENVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:38703
Mailing Address - Country:US
Mailing Address - Phone:662-537-4976
Mailing Address - Fax:662-537-4977
Practice Address - Street 1:1766 OLD LELAND RD
Practice Address - Street 2:
Practice Address - City:GREENVILLE
Practice Address - State:MS
Practice Address - Zip Code:38703
Practice Address - Country:US
Practice Address - Phone:662-537-4976
Practice Address - Fax:662-537-4977
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-11
Last Update Date:2013-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS801597391172A00000X
172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver