Provider Demographics
NPI:1831752005
Name:WILSON, MICHELLE M
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:M
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 1:30 SHERLING AVE
Mailing Address - Street 2:
Mailing Address - City:JEFFERSON
Mailing Address - State:LA
Mailing Address - Zip Code:70121-2200
Mailing Address - Country:US
Mailing Address - Phone:504-312-2534
Mailing Address - Fax:
Practice Address - Street 1:19 LAKES ST
Practice Address - Street 2:
Practice Address - City:NESPELEM
Practice Address - State:WA
Practice Address - Zip Code:99155
Practice Address - Country:US
Practice Address - Phone:800-416-7459
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-15
Last Update Date:2019-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LARN156196163WM0705X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WM0705XNursing Service ProvidersRegistered NurseMedical-Surgical