Provider Demographics
NPI:1629605852
Name:WILSON, COREY
Entity Type:Individual
Prefix:
First Name:COREY
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 1:550 HARBOR COVE LN APT 2300J
Mailing Address - Street 2:
Mailing Address - City:CHARLESTON
Mailing Address - State:SC
Mailing Address - Zip Code:29412-3031
Mailing Address - Country:US
Mailing Address - Phone:803-427-7602
Mailing Address - Fax:
Practice Address - Street 1:600 HILL AVE STE 101
Practice Address - Street 2:
Practice Address - City:NASHVILLE
Practice Address - State:TN
Practice Address - Zip Code:37210-4755
Practice Address - Country:US
Practice Address - Phone:615-329-4790
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-26
Last Update Date:2020-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program