Provider Demographics
NPI:1780991752
Name:WILSON, DEBORAH (ANP-BC)
Entity type:Individual
Prefix:MRS
First Name:DEBORAH
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:ANP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 684
Mailing Address - Street 2:
Mailing Address - City:GLOUCESTER
Mailing Address - State:VA
Mailing Address - Zip Code:23061-0684
Mailing Address - Country:US
Mailing Address - Phone:804-642-9515
Mailing Address - Fax:804-683-3691
Practice Address - Street 1:5690 PARKWAY DR
Practice Address - Street 2:
Practice Address - City:GLOUCESTER
Practice Address - State:VA
Practice Address - Zip Code:23061-3782
Practice Address - Country:US
Practice Address - Phone:804-642-9515
Practice Address - Fax:804-683-3691
Is Sole Proprietor?:No
Enumeration Date:2010-09-11
Last Update Date:2013-11-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024093161363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health