Provider Demographics
NPI:1619114352
Name:WILSON, LORENA LISSETTE (ANP-BC)
Entity Type:Individual
Prefix:
First Name:LORENA
Middle Name:LISSETTE
Last Name:WILSON
Suffix:
Gender:F
Credentials:ANP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 CENTER DRIVE ROOM 9N248D
Mailing Address - Street 2:
Mailing Address - City:BETHESDA
Mailing Address - State:MD
Mailing Address - Zip Code:20892-2631
Mailing Address - Country:US
Mailing Address - Phone:301-385-8748
Mailing Address - Fax:301-480-3054
Practice Address - Street 1:9000 ROCKVILLE PIKE
Practice Address - Street 2:
Practice Address - City:BETHESDA
Practice Address - State:MD
Practice Address - Zip Code:20892-5655
Practice Address - Country:US
Practice Address - Phone:301-385-8748
Practice Address - Fax:301-480-3054
Is Sole Proprietor?:No
Enumeration Date:2009-01-16
Last Update Date:2020-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024168613363LA2200X
DC1005179363LA2200X
MDR180385363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDR180385OtherNURSE PRACTITIONER LICENSE