Provider Demographics
NPI:1881051738
Name:WILSON, CYNTHIA
Entity type:Individual
Prefix:
First Name:CYNTHIA
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 1:128 MAXWELL AVE
Mailing Address - Street 2:SUITE F
Mailing Address - City:GREENWOOD
Mailing Address - State:SC
Mailing Address - Zip Code:29646-2641
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:128 MAXWELL AVE
Practice Address - Street 2:SUITE F
Practice Address - City:GREENWOOD
Practice Address - State:SC
Practice Address - Zip Code:29646-2641
Practice Address - Country:US
Practice Address - Phone:864-715-2445
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-23
Last Update Date:2016-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered