Provider Demographics
NPI:1932380979
Name:WILSON, MARY LOUISE (RN)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:LOUISE
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 1:1342 W. EMERALD AVE
Mailing Address - Street 2:UNIT 256
Mailing Address - City:MESA
Mailing Address - State:AZ
Mailing Address - Zip Code:85202-3344
Mailing Address - Country:US
Mailing Address - Phone:480-668-2766
Mailing Address - Fax:480-668-2766
Practice Address - Street 1:1342 W EMERALD AVE
Practice Address - Street 2:UNIT 256
Practice Address - City:MESA
Practice Address - State:AZ
Practice Address - Zip Code:85202-3379
Practice Address - Country:US
Practice Address - Phone:480-668-2766
Practice Address - Fax:480-668-2766
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-19
Last Update Date:2007-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZRN123027163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health