Provider Demographics
NPI:1396568473
Name:WILSON, MACY MCKIM (REGISTERED NURSE)
Entity type:Individual
Prefix:
First Name:MACY
Middle Name:MCKIM
Last Name:WILSON
Suffix:
Gender:F
Credentials:REGISTERED NURSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:465 JO ALAN CT
Mailing Address - Street 2:
Mailing Address - City:GRAND JUNCTION
Mailing Address - State:CO
Mailing Address - Zip Code:81504-3301
Mailing Address - Country:US
Mailing Address - Phone:970-261-4358
Mailing Address - Fax:
Practice Address - Street 1:465 JO ALAN CT
Practice Address - Street 2:
Practice Address - City:GRAND JUNCTION
Practice Address - State:CO
Practice Address - Zip Code:81504-3301
Practice Address - Country:US
Practice Address - Phone:970-261-4358
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-11-06
Last Update Date:2024-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CORN.1625960163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse