Provider Demographics
NPI:1760813430
Name:WILSON, JANE GALLAUDET (NP-C)
Entity Type:Individual
Prefix:
First Name:JANE
Middle Name:GALLAUDET
Last Name:WILSON
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 9746
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04104-5040
Mailing Address - Country:US
Mailing Address - Phone:207-799-3888
Mailing Address - Fax:
Practice Address - Street 1:114 BATH RD
Practice Address - Street 2:
Practice Address - City:BRUNSWICK
Practice Address - State:ME
Practice Address - Zip Code:04011-2606
Practice Address - Country:US
Practice Address - Phone:207-798-4400
Practice Address - Fax:207-798-4452
Is Sole Proprietor?:No
Enumeration Date:2013-12-06
Last Update Date:2021-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MERN59802163W00000X
MECNP131041363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse