Provider Demographics
NPI:1699862078
Name:WILSON, CAROL (LPN)
Entity type:Individual
Prefix:MRS
First Name:CAROL
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 1:8796 N PAULETTES PL
Mailing Address - Street 2:
Mailing Address - City:BILOXI
Mailing Address - State:MS
Mailing Address - Zip Code:39532-7410
Mailing Address - Country:US
Mailing Address - Phone:228-392-3095
Mailing Address - Fax:228-392-3095
Practice Address - Street 1:8796 N PAULETTES PL
Practice Address - Street 2:
Practice Address - City:BILOXI
Practice Address - State:MS
Practice Address - Zip Code:39532-7410
Practice Address - Country:US
Practice Address - Phone:228-392-3095
Practice Address - Fax:228-392-3095
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-06
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSP165786164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS00770265Medicaid