Provider Demographics
NPI:1699209775
Name:WILSON, GEORGIA (LPN)
Entity Type:Individual
Prefix:MISS
First Name:GEORGIA
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:P.O. BOX 187
Mailing Address - Street 2:
Mailing Address - City:LOWER BRULE
Mailing Address - State:SD
Mailing Address - Zip Code:57548
Mailing Address - Country:US
Mailing Address - Phone:605-473-8243
Mailing Address - Fax:605-473-0607
Practice Address - Street 1:601 GALL ST.
Practice Address - Street 2:
Practice Address - City:LOWER BRULE
Practice Address - State:SD
Practice Address - Zip Code:57548
Practice Address - Country:US
Practice Address - Phone:605-473-8243
Practice Address - Fax:605-473-0607
Is Sole Proprietor?:Yes
Enumeration Date:2017-04-17
Last Update Date:2017-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SDP011717164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse