Provider Demographics
NPI:1801575709
Name:WILSON, AUTUM ELISSA (RN)
Entity type:Individual
Prefix:
First Name:AUTUM
Middle Name:ELISSA
Last Name:WILSON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:314 GROVE NECK RD
Mailing Address - Street 2:
Mailing Address - City:EARLEVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:21919-3008
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:314 GROVE NECK RD
Practice Address - Street 2:
Practice Address - City:EARLEVILLE
Practice Address - State:MD
Practice Address - Zip Code:21919-3008
Practice Address - Country:US
Practice Address - Phone:302-803-1910
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-17
Last Update Date:2023-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEL1-0070251163WA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WA0400XNursing Service ProvidersRegistered NurseAddiction (Substance Use Disorder)