Provider Demographics
NPI:1003337205
Name:WILSON, CHARMAINE JOHNSON (FNP-C)
Entity type:Individual
Prefix:
First Name:CHARMAINE
Middle Name:JOHNSON
Last Name:WILSON
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8 SPLIT ROCK CT
Mailing Address - Street 2:
Mailing Address - City:FRISCO
Mailing Address - State:TX
Mailing Address - Zip Code:75033-0407
Mailing Address - Country:US
Mailing Address - Phone:504-621-5650
Mailing Address - Fax:
Practice Address - Street 1:265 FRANKLIN ST STE 1702
Practice Address - Street 2:
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02110-3144
Practice Address - Country:US
Practice Address - Phone:888-803-3337
Practice Address - Fax:888-803-3331
Is Sole Proprietor?:No
Enumeration Date:2017-06-28
Last Update Date:2024-06-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP134297363LF0000X
MARN2385399363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily