Provider Demographics
NPI:1417762337
Name:WILSON, NICHOLAS (RD)
Entity type:Individual
Prefix:
First Name:NICHOLAS
Middle Name:
Last Name:WILSON
Suffix:
Gender:M
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:727 VANDENBERG DR
Mailing Address - Street 2:
Mailing Address - City:BILOXI
Mailing Address - State:MS
Mailing Address - Zip Code:39531-2654
Mailing Address - Country:US
Mailing Address - Phone:616-848-8033
Mailing Address - Fax:
Practice Address - Street 1:727 VANDENBERG DR
Practice Address - Street 2:
Practice Address - City:BILOXI
Practice Address - State:MS
Practice Address - Zip Code:39531-2654
Practice Address - Country:US
Practice Address - Phone:616-848-8033
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-02-10
Last Update Date:2025-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered