Provider Demographics
NPI:1659758597
Name:WILSON, RUBY DIRONDA (RN)
Entity Type:Individual
Prefix:MISS
First Name:RUBY
Middle Name:DIRONDA
Last Name:WILSON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 3915
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MS
Mailing Address - Zip Code:39207-2707
Mailing Address - Country:US
Mailing Address - Phone:601-500-2542
Mailing Address - Fax:769-208-8014
Practice Address - Street 1:1206 COX ST
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MS
Practice Address - Zip Code:39204-2707
Practice Address - Country:US
Practice Address - Phone:601-500-2542
Practice Address - Fax:769-208-8014
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-29
Last Update Date:2015-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR898458163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS06779560Medicaid