Provider Demographics
NPI:1386062388
Name:WILSON, MARVEL PAMELA
Entity type:Individual
Prefix:
First Name:MARVEL
Middle Name:PAMELA
Last Name:WILSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MARVEL
Other - Middle Name:PAMELA
Other - Last Name:SOARES
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:225 JOHNSON RD APT 38B
Mailing Address - Street 2:
Mailing Address - City:FOREST PARK
Mailing Address - State:GA
Mailing Address - Zip Code:30297-2892
Mailing Address - Country:US
Mailing Address - Phone:404-437-8289
Mailing Address - Fax:
Practice Address - Street 1:225 JOHNSON RD APT 38B
Practice Address - Street 2:
Practice Address - City:FOREST PARK
Practice Address - State:GA
Practice Address - Zip Code:30297-2892
Practice Address - Country:US
Practice Address - Phone:404-437-8289
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-04-07
Last Update Date:2014-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA347C00000X347C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes347C00000XTransportation ServicesPrivate Vehicle