Provider Demographics
NPI:1720580533
Name:WILSON, MARY ELLEN
Entity Type:Individual
Prefix:MRS
First Name:MARY
Middle Name:ELLEN
Last Name:WILSON
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:MARY
Other - Middle Name:ELLEN
Other - Last Name:WILSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1219 CRYSTAL ST
Mailing Address - Street 2:
Mailing Address - City:TOLEDO
Mailing Address - State:OH
Mailing Address - Zip Code:43605-3806
Mailing Address - Country:US
Mailing Address - Phone:419-392-5640
Mailing Address - Fax:
Practice Address - Street 1:1219 CRYSTAL ST
Practice Address - Street 2:
Practice Address - City:TOLEDO
Practice Address - State:OH
Practice Address - Zip Code:43605-3806
Practice Address - Country:US
Practice Address - Phone:419-392-5640
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-03-07
Last Update Date:2018-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide