Basic Information
| Provider Information | |||||||||
| NPI: | 1881844942 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILSON | ||||||||
| FirstName: | RUTH | ||||||||
| MiddleName: | C | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | ARNP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | GREMILLION | ||||||||
| OtherFirstName: | RUTH | ||||||||
| OtherMiddleName: | CONSTANCE | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | RN BSN | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 134 S WOODS DR | ||||||||
| Address2: | |||||||||
| City: | ROCKLEDGE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329553262 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3216363066 | ||||||||
| FaxNumber: | 3216362545 | ||||||||
| Practice Location | |||||||||
| Address1: | 134 S WOODS DR | ||||||||
| Address2: | |||||||||
| City: | ROCKLEDGE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 329553262 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3216363066 | ||||||||
| FaxNumber: | 3216362545 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/25/2008 | ||||||||
| LastUpdateDate: | 09/19/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LP0200X | ARNP898842 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 000437200 | 05 | FL | MEDICAID |