Provider Demographics
NPI:1184934549
Name:WILSON, CRYSTAL M (LPN)
Entity type:Individual
Prefix:
First Name:CRYSTAL
Middle Name:M
Last Name:WILSON
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:270 DOLLY MADISON CT
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31220-2605
Mailing Address - Country:US
Mailing Address - Phone:478-957-7029
Mailing Address - Fax:
Practice Address - Street 1:270 DOLLY MADISON CT
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31220-2605
Practice Address - Country:US
Practice Address - Phone:478-957-7029
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-10-19
Last Update Date:2010-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPN054323164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse