Provider Demographics
NPI:1760078596
Name:WILSON, DEBORAH JEAN
Entity Type:Individual
Prefix:
First Name:DEBORAH
Middle Name:JEAN
Last Name:WILSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:178 FORK RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:MOUNDSVILLE
Mailing Address - State:WV
Mailing Address - Zip Code:26041-3137
Mailing Address - Country:US
Mailing Address - Phone:304-843-1111
Mailing Address - Fax:
Practice Address - Street 1:423 ANNADALE AVE
Practice Address - Street 2:
Practice Address - City:MOUNDSVILLE
Practice Address - State:WV
Practice Address - Zip Code:26041-2042
Practice Address - Country:US
Practice Address - Phone:304-238-4734
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-16
Last Update Date:2020-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant