Provider Demographics
NPI:1962479709
Name:WILSON, NINA MARIE (CNM)
Entity Type:Individual
Prefix:MRS
First Name:NINA
Middle Name:MARIE
Last Name:WILSON
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:100 LILLIAN GISH BLVD SW STE 201
Mailing Address - Street 2:
Mailing Address - City:MASSILLON
Mailing Address - State:OH
Mailing Address - Zip Code:44647-6500
Mailing Address - Country:US
Mailing Address - Phone:716-631-8212
Mailing Address - Fax:716-631-8710
Practice Address - Street 1:100 LILLIAN GISH BLVD SW STE 201
Practice Address - Street 2:
Practice Address - City:MASSILLON
Practice Address - State:OH
Practice Address - Zip Code:44647-6500
Practice Address - Country:US
Practice Address - Phone:330-809-0460
Practice Address - Fax:330-809-0560
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-01
Last Update Date:2020-08-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPRNCNM0019444367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice MidwifeGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYRA4000Medicare ID - Type Unspecified
NYP74131Medicare UPIN