Provider Demographics
NPI:1093399016
Name:ELLY WILSON
Entity type:Organization
Organization Name:ELLY WILSON
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIETITIAN
Authorized Official - Prefix:
Authorized Official - First Name:ELIZABETH
Authorized Official - Middle Name:
Authorized Official - Last Name:WILSON
Authorized Official - Suffix:
Authorized Official - Credentials:RD
Authorized Official - Phone:614-304-1857
Mailing Address - Street 1:937 S 3RD ST APT A
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:OH
Mailing Address - Zip Code:43206-2542
Mailing Address - Country:US
Mailing Address - Phone:419-206-9531
Mailing Address - Fax:
Practice Address - Street 1:937 S 3RD ST APT A
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:OH
Practice Address - Zip Code:43206-2542
Practice Address - Country:US
Practice Address - Phone:614-304-1857
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-05-06
Last Update Date:2021-05-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH1942836556OtherNPI