Provider Demographics
NPI:1659856698
Name:WILMOTH, DEBORAH TRAYLOR (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:
First Name:DEBORAH
Middle Name:TRAYLOR
Last Name:WILMOTH
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 1:264 COUNTY ROAD 3101
Mailing Address - Street 2:
Mailing Address - City:BOONEVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:38829-7854
Mailing Address - Country:US
Mailing Address - Phone:662-416-9510
Mailing Address - Fax:
Practice Address - Street 1:1914 UNIVERSITY AVE
Practice Address - Street 2:
Practice Address - City:OXFORD
Practice Address - State:MS
Practice Address - Zip Code:38655-4114
Practice Address - Country:US
Practice Address - Phone:662-238-7860
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-09-25
Last Update Date:2018-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS902959363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner