Provider Demographics
NPI:1972257244
Name:WILSON, VERONICA MONIQUE
Entity type:Individual
Prefix:
First Name:VERONICA
Middle Name:MONIQUE
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 1:377 S MAHOGANY ST
Mailing Address - Street 2:
Mailing Address - City:JESUP
Mailing Address - State:GA
Mailing Address - Zip Code:31546-5159
Mailing Address - Country:US
Mailing Address - Phone:912-439-9663
Mailing Address - Fax:
Practice Address - Street 1:172 ZORN RD
Practice Address - Street 2:
Practice Address - City:HINESVILLE
Practice Address - State:GA
Practice Address - Zip Code:31313-6902
Practice Address - Country:US
Practice Address - Phone:912-876-4790
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-07
Last Update Date:2022-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA3747A0650X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider