Provider Demographics
NPI:1154528685
Name:WILSON, ELIZABETH ROBIN (CNM)
Entity type:Individual
Prefix:
First Name:ELIZABETH
Middle Name:ROBIN
Last Name:WILSON
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:360 COLLEGE ST
Mailing Address - Street 2:
Mailing Address - City:BLAKELY
Mailing Address - State:GA
Mailing Address - Zip Code:39823-2554
Mailing Address - Country:US
Mailing Address - Phone:229-723-2660
Mailing Address - Fax:229-723-5969
Practice Address - Street 1:916 S BROAD ST
Practice Address - Street 2:
Practice Address - City:THOMASVILLE
Practice Address - State:GA
Practice Address - Zip Code:31792-6113
Practice Address - Country:US
Practice Address - Phone:229-226-8800
Practice Address - Fax:229-226-1660
Is Sole Proprietor?:No
Enumeration Date:2007-06-28
Last Update Date:2015-05-14
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GARN123110367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA217056732BMedicaid
GARN123110OtherLICENSE NUMBER
GA217056732AMedicaid