Provider Demographics
NPI:1609322924
Name:WILSON, PAULINE
Entity Type:Individual
Prefix:
First Name:PAULINE
Middle Name:
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 1:128 FRONT STREET
Mailing Address - Street 2:
Mailing Address - City:SCAMMON BAY
Mailing Address - State:AK
Mailing Address - Zip Code:99662-0150
Mailing Address - Country:US
Mailing Address - Phone:907-558-5511
Mailing Address - Fax:907-558-5705
Practice Address - Street 1:128 FRONT STREET
Practice Address - Street 2:
Practice Address - City:SCAMMON BAY
Practice Address - State:AK
Practice Address - Zip Code:99662-0150
Practice Address - Country:US
Practice Address - Phone:907-758-4711
Practice Address - Fax:907-758-3540
Is Sole Proprietor?:No
Enumeration Date:2016-08-28
Last Update Date:2022-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker