Provider Demographics
NPI:1184298671
Name:WILSON, CAROLYN DEANNA
Entity type:Individual
Prefix:
First Name:CAROLYN
Middle Name:DEANNA
Last Name:WILSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:CAROLYN
Other - Middle Name:DEANNA
Other - Last Name:POORE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:2425 STOCKTON BLVD
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95817-2215
Mailing Address - Country:US
Mailing Address - Phone:916-453-5057
Mailing Address - Fax:
Practice Address - Street 1:2425 STOCKTON BLVD
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95817-2215
Practice Address - Country:US
Practice Address - Phone:916-453-5057
Practice Address - Fax:916-453-5038
Is Sole Proprietor?:No
Enumeration Date:2021-05-18
Last Update Date:2023-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA950866896163WM0705X, 163WP0200X, 163WC0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC0400XNursing Service ProvidersRegistered NurseCase Management
No163WM0705XNursing Service ProvidersRegistered NurseMedical-Surgical
No163WP0200XNursing Service ProvidersRegistered NursePediatrics