Provider Demographics
NPI:1558738641
Name:WILSON, CAROL ELLEN (RN, MSN)
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:ELLEN
Last Name:WILSON
Suffix:
Gender:F
Credentials:RN, MSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:713 THRASHER AVE NE
Mailing Address - Street 2:
Mailing Address - City:NORTH BEND
Mailing Address - State:WA
Mailing Address - Zip Code:98045-7919
Mailing Address - Country:US
Mailing Address - Phone:425-888-0110
Mailing Address - Fax:
Practice Address - Street 1:205 8TH ST
Practice Address - Street 2:
Practice Address - City:HOQUIAM
Practice Address - State:WA
Practice Address - Zip Code:98550-2507
Practice Address - Country:US
Practice Address - Phone:360-236-5328
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-08-25
Last Update Date:2022-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WARN00086590163WP0808X, 163W00000X, 101YM0800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WAWAC 3888650150OtherMENTAL HEALTH PROFESSIONAL BY MENTAL HEALTH DIVISION OF WA STATE
0216286OtherNATIONAL CERTIFICATION IN PSYCHIATRIC AND MENTAL HEALTH NURSING
WARN00086590OtherRN