Provider Demographics
NPI:1699337717
Name:MARK-WILSON, PRISCILLA
Entity type:Individual
Prefix:
First Name:PRISCILLA
Middle Name:
Last Name:MARK-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 1:3350 NOOR WAY
Mailing Address - Street 2:
Mailing Address - City:DOUGLASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30135-8172
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:3350 NOOR WAY
Practice Address - Street 2:
Practice Address - City:DOUGLASVILLE
Practice Address - State:GA
Practice Address - Zip Code:30135-8172
Practice Address - Country:US
Practice Address - Phone:404-981-9111
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-06-29
Last Update Date:2019-06-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
No341600000XTransportation ServicesAmbulance
No3416L0300XTransportation ServicesAmbulanceLand Transport