Provider Demographics
NPI:1417549965
Name:WILSON, TAMARA
Entity type:Individual
Prefix:
First Name:TAMARA
Middle Name:
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 1:5630 LIVINGSTON TER APT 202
Mailing Address - Street 2:
Mailing Address - City:OXON HILL
Mailing Address - State:MD
Mailing Address - Zip Code:20745-2465
Mailing Address - Country:US
Mailing Address - Phone:240-253-3162
Mailing Address - Fax:
Practice Address - Street 1:5630 LIVINGSTON TER APT 202
Practice Address - Street 2:
Practice Address - City:OXON HILL
Practice Address - State:MD
Practice Address - Zip Code:20745-2465
Practice Address - Country:US
Practice Address - Phone:240-253-3162
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-02-05
Last Update Date:2021-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDA00166820376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide