Provider Demographics
NPI:1427481613
Name:WILSON, DIANA JEAN
Entity type:Individual
Prefix:
First Name:DIANA
Middle Name:JEAN
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 1:6414 FANNIN ST STE G125
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77030-1518
Mailing Address - Country:US
Mailing Address - Phone:832-325-7093
Mailing Address - Fax:
Practice Address - Street 1:921 GESSNER RD
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77024-2501
Practice Address - Country:US
Practice Address - Phone:713-242-3650
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-12
Last Update Date:2018-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP111838363LN0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LN0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal