Provider Demographics
NPI:1184340747
Name:WILSON, MILLICENT (RD, LD)
Entity type:Individual
Prefix:MRS
First Name:MILLICENT
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:RD, LD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1002 LAUREL CV
Mailing Address - Street 2:
Mailing Address - City:BUDA
Mailing Address - State:TX
Mailing Address - Zip Code:78610-2872
Mailing Address - Country:US
Mailing Address - Phone:936-615-8355
Mailing Address - Fax:
Practice Address - Street 1:1002 LAUREL CV
Practice Address - Street 2:
Practice Address - City:BUDA
Practice Address - State:TX
Practice Address - Zip Code:78610-2872
Practice Address - Country:US
Practice Address - Phone:936-615-8355
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-17
Last Update Date:2022-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXDT83426133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered