Provider Demographics
NPI:1639266067
Name:WILSON, MARJORIE S (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:MS
First Name:MARJORIE
Middle Name:S
Last Name:WILSON
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1909 N MITCHELL ST
Mailing Address - Street 2:
Mailing Address - City:CADILLAC
Mailing Address - State:MI
Mailing Address - Zip Code:49601
Mailing Address - Country:US
Mailing Address - Phone:231-775-4401
Mailing Address - Fax:
Practice Address - Street 1:815 BUSINESS PARK DR STE A
Practice Address - Street 2:
Practice Address - City:TRAVERSE CITY
Practice Address - State:MI
Practice Address - Zip Code:49686-8683
Practice Address - Country:US
Practice Address - Phone:231-421-6921
Practice Address - Fax:231-421-7852
Is Sole Proprietor?:No
Enumeration Date:2006-10-06
Last Update Date:2021-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704191507363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health