Provider Demographics
NPI:1215543343
Name:WILSON, TAYLOR (MS, RD)
Entity type:Individual
Prefix:
First Name:TAYLOR
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:MS, RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6 GLENWOOD PL
Mailing Address - Street 2:
Mailing Address - City:SPRING LAKE
Mailing Address - State:NJ
Mailing Address - Zip Code:07762-1618
Mailing Address - Country:US
Mailing Address - Phone:856-304-3134
Mailing Address - Fax:
Practice Address - Street 1:6 GLENWOOD PL
Practice Address - Street 2:
Practice Address - City:SPRING LAKE
Practice Address - State:NJ
Practice Address - Zip Code:07762-1618
Practice Address - Country:US
Practice Address - Phone:856-304-3134
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-23
Last Update Date:2021-01-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCDI100001165133V00000X
NJ86120013133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty