Provider Demographics
NPI:1316018955
Name:WILSON, NANCY LOU (OD)
Entity type:Individual
Prefix:DR
First Name:NANCY
Middle Name:LOU
Last Name:WILSON
Suffix:
Gender:F
Credentials:OD
Other - Prefix:DR
Other - First Name:NANCY
Other - Middle Name:LOU
Other - Last Name:WILSON
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:OD
Mailing Address - Street 1:4505 BARRANCA PKWY STE C
Mailing Address - Street 2:
Mailing Address - City:IRVINE
Mailing Address - State:CA
Mailing Address - Zip Code:92604-4797
Mailing Address - Country:US
Mailing Address - Phone:949-857-0676
Mailing Address - Fax:949-857-2175
Practice Address - Street 1:4505 BARRANCA PKWY STE C
Practice Address - Street 2:
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92604-4797
Practice Address - Country:US
Practice Address - Phone:949-857-0676
Practice Address - Fax:949-857-2175
Is Sole Proprietor?:No
Enumeration Date:2006-11-13
Last Update Date:2017-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAOPT8049152W00000X
CA8049T152WC0802X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152WC0802XEye and Vision Services ProvidersOptometristCorneal and Contact Management
Yes152W00000XEye and Vision Services ProvidersOptometrist