Provider Demographics
NPI:1972847747
Name:WILSON, LAUREN E (PNP)
Entity Type:Individual
Prefix:
First Name:LAUREN
Middle Name:E
Last Name:WILSON
Suffix:
Gender:F
Credentials:PNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:425 UNIVERSITY AVENUE
Mailing Address - Street 2:SUITE 200
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95825
Mailing Address - Country:US
Mailing Address - Phone:916-924-9337
Mailing Address - Fax:916-924-8281
Practice Address - Street 1:425 UNIVERSITY AVENUE
Practice Address - Street 2:SUITE 200
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95825
Practice Address - Country:US
Practice Address - Phone:916-924-9337
Practice Address - Fax:916-924-8281
Is Sole Proprietor?:No
Enumeration Date:2012-11-19
Last Update Date:2012-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA22479208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics