Basic Information
| Provider Information | |||||||||
| NPI: | 1275509580 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WILSON | ||||||||
| FirstName: | JOHNNIE | ||||||||
| MiddleName: | S | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3406 COLLEGE ST | ||||||||
| Address2: | ATTN: LEGAL DEPT. | ||||||||
| City: | BEAUMONT | ||||||||
| State: | TX | ||||||||
| PostalCode: | 777014612 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4098132332 | ||||||||
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| Practice Location | |||||||||
| Address1: | 207 E COURT ST | ||||||||
| Address2: | |||||||||
| City: | NEWTON | ||||||||
| State: | TX | ||||||||
| PostalCode: | 759663203 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4093792647 | ||||||||
| FaxNumber: | 4093792349 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/27/2006 | ||||||||
| LastUpdateDate: | 06/27/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 535111 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 535111 | 01 | TX | RN LICENSE | OTHER |