Provider Demographics
NPI:1619398468
Name:FRU, WILSON (HHA)
Entity Type:Individual
Prefix:
First Name:WILSON
Middle Name:
Last Name:FRU
Suffix:
Gender:M
Credentials:HHA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9014 BREEZEWOOD TER APT 104
Mailing Address - Street 2:
Mailing Address - City:GREENBELT
Mailing Address - State:MD
Mailing Address - Zip Code:20770-4012
Mailing Address - Country:US
Mailing Address - Phone:301-256-8332
Mailing Address - Fax:
Practice Address - Street 1:2010 RHODE ISLAND AVE NE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20018-2835
Practice Address - Country:US
Practice Address - Phone:202-526-3535
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-12-20
Last Update Date:2013-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCHHA10193374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide