Provider Demographics
NPI:1427337559
Name:WILSON, ROXANNE MILES (MN,FNP/GNP,DSD,PHN,C)
Entity type:Individual
Prefix:MS
First Name:ROXANNE
Middle Name:MILES
Last Name:WILSON
Suffix:
Gender:F
Credentials:MN,FNP/GNP,DSD,PHN,C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5140 YOLANDA AVE
Mailing Address - Street 2:
Mailing Address - City:TARZANA
Mailing Address - State:CA
Mailing Address - Zip Code:91356-4027
Mailing Address - Country:US
Mailing Address - Phone:818-344-8646
Mailing Address - Fax:
Practice Address - Street 1:5140 YOLANDA AVE
Practice Address - Street 2:
Practice Address - City:TARZANA
Practice Address - State:CA
Practice Address - Zip Code:91356-4027
Practice Address - Country:US
Practice Address - Phone:818-344-8646
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-07
Last Update Date:2018-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA6708363LG0600X
CARN362861363LF0000X, 363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily