Provider Demographics
NPI:1821847021
Name:WILSON, DENISE
Entity type:Individual
Prefix:
First Name:DENISE
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2493 CORNER SHOALS DR
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30034-1224
Mailing Address - Country:US
Mailing Address - Phone:404-226-8576
Mailing Address - Fax:
Practice Address - Street 1:2493 CORNER SHOALS DR
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30034-1224
Practice Address - Country:US
Practice Address - Phone:404-226-8576
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-05-18
Last Update Date:2024-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health