Provider Demographics
NPI:1578563573
Name:WILK, MARY C (FNP)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:C
Last Name:WILK
Suffix:
Gender:F
Credentials:FNP
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 660599
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75266-0599
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5000 HARRY HINES BLVD
Practice Address - Street 2:HOMES
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75235-7721
Practice Address - Country:US
Practice Address - Phone:214-590-0153
Practice Address - Fax:214-590-0172
Is Sole Proprietor?:No
Enumeration Date:2005-08-01
Last Update Date:2009-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX418884363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX138633602Medicaid
TX138633611Medicaid
TX138633607Medicaid
TX138633601Medicaid
TX138633608Medicaid
TX138633610Medicaid
TX138633612Medicaid
TX138633605Medicaid
TX138633603Medicaid
TX138633604Medicaid
TX138633613Medicaid
TX138633602Medicaid
TX138633613Medicaid