Provider Demographics
NPI:1730148123
Name:WILBON, ROSIE ANN (N P)
Entity type:Individual
Prefix:MS
First Name:ROSIE
Middle Name:ANN
Last Name:WILBON
Suffix:
Gender:F
Credentials:N P
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 446
Mailing Address - Street 2:721 CEDAR CREEK ROAD
Mailing Address - City:MACON
Mailing Address - State:MS
Mailing Address - Zip Code:39341-0446
Mailing Address - Country:US
Mailing Address - Phone:662-726-5311
Mailing Address - Fax:
Practice Address - Street 1:606 N JEFFERSON ST
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:MS
Practice Address - Zip Code:39341-2242
Practice Address - Country:US
Practice Address - Phone:662-726-4264
Practice Address - Fax:662-726-4956
Is Sole Proprietor?:Yes
Enumeration Date:2006-03-22
Last Update Date:2013-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR683205363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSP76637Medicare UPIN