Provider Demographics
NPI:1285284570
Name:WILSON, SIMONE THERESE (MS, RD, LDN)
Entity type:Individual
Prefix:
First Name:SIMONE
Middle Name:THERESE
Last Name:WILSON
Suffix:
Gender:F
Credentials:MS, RD, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 29277
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19125-0977
Mailing Address - Country:US
Mailing Address - Phone:828-553-6832
Mailing Address - Fax:
Practice Address - Street 1:457 BELGRADE ST
Practice Address - Street 2:
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19125-2624
Practice Address - Country:US
Practice Address - Phone:828-553-6832
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-18
Last Update Date:2019-09-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY86096718133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Single Specialty