Provider Demographics
NPI:1710436274
Name:WILSON, THERESA MAE (RN)
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:MAE
Last Name:WILSON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:THERESA
Other - Middle Name:MAE
Other - Last Name:CORNETT
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:205 W PARK ST
Mailing Address - Street 2:
Mailing Address - City:OAK HARBOR
Mailing Address - State:OH
Mailing Address - Zip Code:43449-1239
Mailing Address - Country:US
Mailing Address - Phone:304-989-3003
Mailing Address - Fax:
Practice Address - Street 1:205 W PARK ST
Practice Address - Street 2:
Practice Address - City:OAK HARBOR
Practice Address - State:OH
Practice Address - Zip Code:43449-1239
Practice Address - Country:US
Practice Address - Phone:304-989-3003
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-26
Last Update Date:2016-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHRN.342947163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse