Provider Demographics
NPI:1457716896
Name:WILSON, ADJOKO (RN, BSN, PHN)
Entity Type:Individual
Prefix:
First Name:ADJOKO
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:RN, BSN, PHN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1800 2ND ST NE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55418-4306
Mailing Address - Country:US
Mailing Address - Phone:612-789-1236
Mailing Address - Fax:
Practice Address - Street 1:1800 2ND ST NE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55418-4306
Practice Address - Country:US
Practice Address - Phone:612-789-1236
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-12-30
Last Update Date:2015-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR 201029-2163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNR 201029-2OtherSTATE LICENSE