Provider Demographics
NPI:1790440105
Name:WILSON, ELIZABETH ANNE
Entity Type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:ANNE
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:PO BOX 144
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:WV
Mailing Address - Zip Code:24712-0144
Mailing Address - Country:US
Mailing Address - Phone:910-322-6796
Mailing Address - Fax:
Practice Address - Street 1:105 CLIFFTOP DR
Practice Address - Street 2:
Practice Address - City:BEAVER
Practice Address - State:WV
Practice Address - Zip Code:25813-9301
Practice Address - Country:US
Practice Address - Phone:304-254-8524
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-11-02
Last Update Date:2021-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant