Provider Demographics
NPI:1598498735
Name:WILSON, DANIELLE DESTIN (CNM, FNP-C)
Entity Type:Individual
Prefix:
First Name:DANIELLE
Middle Name:DESTIN
Last Name:WILSON
Suffix:
Gender:F
Credentials:CNM, FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3430 ELM AVE
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21211-2417
Mailing Address - Country:US
Mailing Address - Phone:305-878-7335
Mailing Address - Fax:
Practice Address - Street 1:7501 GREENWAY CENTER DR # 910
Practice Address - Street 2:
Practice Address - City:GREENBELT
Practice Address - State:MD
Practice Address - Zip Code:20770-3514
Practice Address - Country:US
Practice Address - Phone:305-878-7335
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-06
Last Update Date:2022-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDAC004510367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife