Provider Demographics
NPI:1972773620
Name:WILSON, LAURIE DODGE (RN, ANP-BC, GNP-BC)
Entity type:Individual
Prefix:MRS
First Name:LAURIE
Middle Name:DODGE
Last Name:WILSON
Suffix:
Gender:F
Credentials:RN, ANP-BC, GNP-BC
Other - Prefix:MISS
Other - First Name:LAURIE
Other - Middle Name:FLINT
Other - Last Name:DODGE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APRN, ANP, GNP, BC
Mailing Address - Street 1:2150 PENNSYLVANIA AVE NW
Mailing Address - Street 2:#5-411
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20037-3201
Mailing Address - Country:US
Mailing Address - Phone:202-742-3398
Mailing Address - Fax:202-741-3396
Practice Address - Street 1:2150 PENNSYLVANIA AVE NW
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20037-3201
Practice Address - Country:US
Practice Address - Phone:202-741-3333
Practice Address - Fax:202-741-2791
Is Sole Proprietor?:No
Enumeration Date:2008-03-10
Last Update Date:2008-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCRN1013020363LA2200X, 363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TXP24633Medicare UPIN