| NPI | 1699086025 |
|---|---|
| Former Name | STEPHANIE TARA WILSON |
| Entity Type | Individual |
| Gender | Female |
| Sole Proprietor ? | No |
| Primary Taxonomy | 363LP0200X Nurse Practitioner Pediatrics (Licence: GA RN169676) |
| Additional Taxonomies | 163W00000X Registered Nurse (Licence: GA RN169676) |
| Enumeration Date | 2010-06-30 |
| Last Update Date | 2014-03-04 |