Provider Demographics
NPI:1578050670
Name:WILSON, RENAE HUGHES
Entity Type:Individual
Prefix:
First Name:RENAE
Middle Name:HUGHES
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:PO BOX 205
Mailing Address - Street 2:
Mailing Address - City:METTER
Mailing Address - State:GA
Mailing Address - Zip Code:30439-0205
Mailing Address - Country:US
Mailing Address - Phone:912-685-5765
Mailing Address - Fax:
Practice Address - Street 1:428 N ROUNTREE ST
Practice Address - Street 2:
Practice Address - City:METTER
Practice Address - State:GA
Practice Address - Zip Code:30439-3702
Practice Address - Country:US
Practice Address - Phone:912-685-5765
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-16
Last Update Date:2018-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALD004572133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered