Provider Demographics
NPI:1730133661
Name:WILSON, COLLEEN M (NP)
Entity Type:Individual
Prefix:
First Name:COLLEEN
Middle Name:M
Last Name:WILSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:147 MILK ST
Mailing Address - Street 2:
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02109-4806
Mailing Address - Country:US
Mailing Address - Phone:617-421-2508
Mailing Address - Fax:617-421-3487
Practice Address - Street 1:228 BILLERICA RD
Practice Address - Street 2:
Practice Address - City:CHELMSFORD
Practice Address - State:MA
Practice Address - Zip Code:01824-3604
Practice Address - Country:US
Practice Address - Phone:978-250-6100
Practice Address - Fax:978-250-6472
Is Sole Proprietor?:No
Enumeration Date:2006-05-22
Last Update Date:2010-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA194864363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAAA53966OtherHARVARD PILGRIM
MANP5272Medicare ID - Type Unspecified
MAAA53966OtherHARVARD PILGRIM