Provider Demographics
NPI:1619375888
Name:WILSON, MILDRED (RN)
Entity type:Individual
Prefix:
First Name:MILDRED
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2410 METTE RD
Mailing Address - Street 2:
Mailing Address - City:WENTZVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:63385-2108
Mailing Address - Country:US
Mailing Address - Phone:636-578-8422
Mailing Address - Fax:
Practice Address - Street 1:2410 METTE RD
Practice Address - Street 2:
Practice Address - City:WENTZVILLE
Practice Address - State:MO
Practice Address - Zip Code:63385-2108
Practice Address - Country:US
Practice Address - Phone:636-578-8422
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-12-19
Last Update Date:2014-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2011016002163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse