Provider Demographics
NPI:1306056668
Name:WILSON, MILLIE B
Entity type:Individual
Prefix:MS
First Name:MILLIE
Middle Name:B
Last Name:WILSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1113 PORTER ST APT C
Mailing Address - Street 2:
Mailing Address - City:VALLEJO
Mailing Address - State:CA
Mailing Address - Zip Code:94590-7910
Mailing Address - Country:US
Mailing Address - Phone:505-977-1316
Mailing Address - Fax:
Practice Address - Street 1:1113 PORTER ST APT C
Practice Address - Street 2:
Practice Address - City:VALLEJO
Practice Address - State:CA
Practice Address - Zip Code:94590-7910
Practice Address - Country:US
Practice Address - Phone:505-977-1316
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-23
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT 21765167G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes167G00000XNursing Service ProvidersLicensed Psychiatric Technician