Provider Demographics
NPI:1235958802
Name:WILSON, DEBRA ELIZABETH
Entity type:Individual
Prefix:
First Name:DEBRA
Middle Name:ELIZABETH
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 1:222 CYPRESS AVE APT 1
Mailing Address - Street 2:
Mailing Address - City:WOODLYNNE
Mailing Address - State:NJ
Mailing Address - Zip Code:08107-2122
Mailing Address - Country:US
Mailing Address - Phone:856-375-4246
Mailing Address - Fax:
Practice Address - Street 1:6103 WESTFIELD AVE
Practice Address - Street 2:
Practice Address - City:PENNSAUKEN
Practice Address - State:NJ
Practice Address - Zip Code:08110-1754
Practice Address - Country:US
Practice Address - Phone:856-486-9097
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-09
Last Update Date:2024-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NPO4515300164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse