Provider Demographics
NPI:1447481502
Name:WILSON, THERESA CECELIA (PNP)
Entity type:Individual
Prefix:MS
First Name:THERESA
Middle Name:CECELIA
Last Name:WILSON
Suffix:
Gender:F
Credentials:PNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:210 W 139TH ST
Mailing Address - Street 2:C/O EDWARD NICHOLS MD
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10030-2109
Mailing Address - Country:US
Mailing Address - Phone:212-234-2121
Mailing Address - Fax:212-234-1759
Practice Address - Street 1:210 W 139TH ST
Practice Address - Street 2:C/O EDWARD NICHOLS MD
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10030-2109
Practice Address - Country:US
Practice Address - Phone:212-234-2121
Practice Address - Fax:212-234-1759
Is Sole Proprietor?:No
Enumeration Date:2009-08-06
Last Update Date:2009-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY380137363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02146716Medicaid