Provider Demographics
NPI:1386808574
Name:WILSON, JEANINE PARKS (MSN)
Entity type:Individual
Prefix:MRS
First Name:JEANINE
Middle Name:PARKS
Last Name:WILSON
Suffix:
Gender:F
Credentials:MSN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:341 SAINT JULIAN PL
Mailing Address - Street 2:
Mailing Address - City:NORTH AUGUSTA
Mailing Address - State:SC
Mailing Address - Zip Code:29860-8795
Mailing Address - Country:US
Mailing Address - Phone:803-278-5502
Mailing Address - Fax:
Practice Address - Street 1:1350 WALTON WAY
Practice Address - Street 2:NEONATAL INTENSIVE CARE UNIT
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30901-2612
Practice Address - Country:US
Practice Address - Phone:706-774-2591
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-07-16
Last Update Date:2008-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN145211163WN0002X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WN0002XNursing Service ProvidersRegistered NurseNeonatal Intensive Care