Provider Demographics
NPI:1912087669
Name:WILSON, VITA J (CFNP)
Entity Type:Individual
Prefix:
First Name:VITA
Middle Name:J
Last Name:WILSON
Suffix:
Gender:F
Credentials:CFNP
Other - Prefix:
Other - First Name:VITA
Other - Middle Name:J
Other - Last Name:WILSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:FNP
Mailing Address - Street 1:1452 TALLY HO CIR
Mailing Address - Street 2:
Mailing Address - City:GULFPORT
Mailing Address - State:MS
Mailing Address - Zip Code:39507-4229
Mailing Address - Country:US
Mailing Address - Phone:228-896-7568
Mailing Address - Fax:
Practice Address - Street 1:250 BEAUVOIR RD STE 5
Practice Address - Street 2:
Practice Address - City:BILOXI
Practice Address - State:MS
Practice Address - Zip Code:39531-4026
Practice Address - Country:US
Practice Address - Phone:228-388-2599
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-17
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR671908363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily