Provider Demographics
NPI:1427608652
Name:WILSON, ROBIN (LPN)
Entity type:Individual
Prefix:
First Name:ROBIN
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:789 WILLIAMSON RD
Mailing Address - Street 2:
Mailing Address - City:TALLAPOOSA
Mailing Address - State:GA
Mailing Address - Zip Code:30176-3936
Mailing Address - Country:US
Mailing Address - Phone:770-634-8528
Mailing Address - Fax:
Practice Address - Street 1:122 GORDON COMMERCIAL DR STE C
Practice Address - Street 2:
Practice Address - City:LAGRANGE
Practice Address - State:GA
Practice Address - Zip Code:30240-5754
Practice Address - Country:US
Practice Address - Phone:706-845-4045
Practice Address - Fax:706-845-4367
Is Sole Proprietor?:No
Enumeration Date:2019-09-19
Last Update Date:2019-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GALPN063310164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse