Provider Demographics
NPI:1881844942
Name:WILSON, RUTH C (ARNP)
Entity type:Individual
Prefix:
First Name:RUTH
Middle Name:C
Last Name:WILSON
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:RUTH
Other - Middle Name:CONSTANCE
Other - Last Name:GREMILLION
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN BSN
Mailing Address - Street 1:134 S WOODS DR
Mailing Address - Street 2:
Mailing Address - City:ROCKLEDGE
Mailing Address - State:FL
Mailing Address - Zip Code:32955-3262
Mailing Address - Country:US
Mailing Address - Phone:321-636-3066
Mailing Address - Fax:321-636-2545
Practice Address - Street 1:134 S WOODS DR
Practice Address - Street 2:
Practice Address - City:ROCKLEDGE
Practice Address - State:FL
Practice Address - Zip Code:32955-3262
Practice Address - Country:US
Practice Address - Phone:321-636-3066
Practice Address - Fax:321-636-2545
Is Sole Proprietor?:No
Enumeration Date:2008-09-25
Last Update Date:2013-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP898842363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL000437200Medicaid