Provider Demographics
NPI:1598931370
Name:WILSON, ELLEN ROSSER (AUD)
Entity Type:Individual
Prefix:
First Name:ELLEN
Middle Name:ROSSER
Last Name:WILSON
Suffix:
Gender:F
Credentials:AUD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1915 K M WICKER MEMORIAL DR
Mailing Address - Street 2:CENTRAL CAROLINA ENT ASSOCIATES
Mailing Address - City:SANFORD
Mailing Address - State:NC
Mailing Address - Zip Code:27330-5070
Mailing Address - Country:US
Mailing Address - Phone:919-774-6829
Mailing Address - Fax:919-775-2327
Practice Address - Street 1:1915 K M WICKER MEMORIAL DR
Practice Address - Street 2:CENTRAL CAROLINA ENT ASSOCIATES
Practice Address - City:SANFORD
Practice Address - State:NC
Practice Address - Zip Code:27330-5070
Practice Address - Country:US
Practice Address - Phone:919-774-6829
Practice Address - Fax:919-775-2327
Is Sole Proprietor?:No
Enumeration Date:2008-05-01
Last Update Date:2009-09-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2126231H00000X
NC588237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes231H00000XSpeech, Language and Hearing Service ProvidersAudiologist
No237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC890107WMedicaid
2126OtherAUDIOLOGIST LICENSE #
NC3404108OtherMEDICAID HEARING AID VENDOR