Provider Demographics
NPI:1720202427
Name:WILSON, MARY E (RN, BSN)
Entity Type:Individual
Prefix:MISS
First Name:MARY
Middle Name:E
Last Name:WILSON
Suffix:
Gender:F
Credentials:RN, BSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2499 KAPIOLANI BLVD
Mailing Address - Street 2:#3509
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96826-5310
Mailing Address - Country:US
Mailing Address - Phone:808-375-7565
Mailing Address - Fax:808-942-4001
Practice Address - Street 1:2499 KAPIOLANI BLVD
Practice Address - Street 2:#3509
Practice Address - City:HONOLULU
Practice Address - State:HI
Practice Address - Zip Code:96826-5339
Practice Address - Country:US
Practice Address - Phone:808-375-7565
Practice Address - Fax:808-942-4001
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HI38843163WC0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC0400XNursing Service ProvidersRegistered NurseCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
HI573734-01Medicare UPIN