| Doctor Name: | DR. NICOLE EDITH WILSON |
| NPI Number: | 1073806956 |
| Entity Type Code: | Individual (1) |
| Gender: | F |
| Credentials: | D.P.M. |
| License Number: | POD001284 |
| Business Practice Address: | 204 Westside Dr Douglas, GA - 315333528 |
| Business Phone Number: | 9123844121 |
| Business Fax Number: | 9123891817 |
| Mailing Address: | 204 Westside Dr, DOUGLAS |
| State: | GA |
| Postal Code: | 315333528 |
| Phone Number: | 9123844121 |
| Fax Number: | 9123891817 |
| NPI Enumeration Date: | 05/25/2011 |
| NPI Last Update Date: | 02/25/2016 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 213ES0103X |
| License Number: | POD001284 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | GA |
| Taxonomy Type: | Podiatric Medicine & Surgery Service Providers |
| Taxonomy Classification: | Podiatrist |
| Taxonomy Specialization: | Foot & Ankle Surgery |
| Taxonomy Definition: | |