Provider Demographics
NPI:1679762090
Name:WILSON, DEBORAH (RD, LDN)
Entity type:Individual
Prefix:MRS
First Name:DEBORAH
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:RD, LDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:503 TRADE ST
Mailing Address - Street 2:
Mailing Address - City:TARBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27886-4321
Mailing Address - Country:US
Mailing Address - Phone:252-824-7657
Mailing Address - Fax:252-824-1479
Practice Address - Street 1:901 N WINSTEAD AVE
Practice Address - Street 2:
Practice Address - City:ROCKY MOUNT
Practice Address - State:NC
Practice Address - Zip Code:27804-8467
Practice Address - Country:US
Practice Address - Phone:252-937-0262
Practice Address - Fax:252-937-0445
Is Sole Proprietor?:No
Enumeration Date:2007-10-22
Last Update Date:2008-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCL002423133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC2993114Medicare PIN