Provider Demographics
NPI:1184394090
Name:WILSON, LUCRETIA D (PMHNP-BC)
Entity type:Individual
Prefix:DR
First Name:LUCRETIA
Middle Name:D
Last Name:WILSON
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:201 SIGMA DR STE 300
Mailing Address - Street 2:
Mailing Address - City:SUMMERVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29486-7722
Mailing Address - Country:US
Mailing Address - Phone:843-418-8771
Mailing Address - Fax:970-591-9592
Practice Address - Street 1:201 SIGMA DR STE 300
Practice Address - Street 2:
Practice Address - City:SUMMERVILLE
Practice Address - State:SC
Practice Address - Zip Code:29486-7722
Practice Address - Country:US
Practice Address - Phone:843-418-8771
Practice Address - Fax:970-591-9592
Is Sole Proprietor?:Yes
Enumeration Date:2021-09-14
Last Update Date:2024-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC25299363L00000X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner