Provider Demographics
NPI:1447470562
Name:WILSON, YVONNE URSULA (RN)
Entity type:Individual
Prefix:MS
First Name:YVONNE
Middle Name:URSULA
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 1:65 COLIN DR
Mailing Address - Street 2:
Mailing Address - City:SHIRLEY
Mailing Address - State:NY
Mailing Address - Zip Code:11967
Mailing Address - Country:US
Mailing Address - Phone:631-495-2967
Mailing Address - Fax:631-924-6904
Practice Address - Street 1:65 COLIN DR
Practice Address - Street 2:
Practice Address - City:SHIRLEY
Practice Address - State:NY
Practice Address - Zip Code:11967-1583
Practice Address - Country:US
Practice Address - Phone:631-495-2967
Practice Address - Fax:631-924-6904
Is Sole Proprietor?:No
Enumeration Date:2007-04-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY5172981163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02077714OtherMEDICAID PROVIDER ID DEPA