Provider Demographics
NPI:1770985327
Name:WILSON, NANCY LEIGH (MT)
Entity type:Individual
Prefix:
First Name:NANCY
Middle Name:LEIGH
Last Name:WILSON
Suffix:
Gender:F
Credentials:MT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:117 EDDIE DOWLING HWY
Mailing Address - Street 2:SUITE 1C
Mailing Address - City:NORTH SMITHFIELD
Mailing Address - State:RI
Mailing Address - Zip Code:02896-7337
Mailing Address - Country:US
Mailing Address - Phone:401-648-5563
Mailing Address - Fax:
Practice Address - Street 1:117 EDDIE DOWLING HWY
Practice Address - Street 2:SUITE 1C
Practice Address - City:NORTH SMITHFIELD
Practice Address - State:RI
Practice Address - Zip Code:02896-7337
Practice Address - Country:US
Practice Address - Phone:401-648-5563
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-25
Last Update Date:2014-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
RIMT01480174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist