Provider Demographics
NPI:1841226875
Name:WILSON, LAURIE A (NP)
Entity Type:Individual
Prefix:
First Name:LAURIE
Middle Name:A
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 1:311 DORIC AVE
Mailing Address - Street 2:
Mailing Address - City:CRANSTON
Mailing Address - State:RI
Mailing Address - Zip Code:02910-2903
Mailing Address - Country:US
Mailing Address - Phone:401-467-9610
Mailing Address - Fax:401-223-0121
Practice Address - Street 1:1090 CRANSTON ST
Practice Address - Street 2:
Practice Address - City:CRANSTON
Practice Address - State:RI
Practice Address - Zip Code:02920-7323
Practice Address - Country:US
Practice Address - Phone:401-467-9610
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-23
Last Update Date:2023-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIAPRN00412363LA2200X
MACNP164706363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MAS400296656Medicare PIN
MALW 51261Medicaid
MAS47269Medicare UPIN