Provider Demographics
NPI:1679042790
Name:WILSON, PATTY R (CRNP-PMH, PHD)
Entity Type:Individual
Prefix:
First Name:PATTY
Middle Name:R
Last Name:WILSON
Suffix:
Gender:F
Credentials:CRNP-PMH, PHD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:525 N WOLFE ST
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21205-2110
Mailing Address - Country:US
Mailing Address - Phone:410-929-0104
Mailing Address - Fax:
Practice Address - Street 1:800 N CHARLES ST STE 4R
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21201-5318
Practice Address - Country:US
Practice Address - Phone:240-304-3327
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-19
Last Update Date:2024-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR122302363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health