Basic Information
| Provider Information | |||||||||
| NPI: | 1902984164 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | STANLEY | ||||||||
| FirstName: | CHRISTIAN | ||||||||
| MiddleName: | WILSON | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | APN | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 191 | ||||||||
| Address2: | PROVIDER ENROLLMENT DEPT | ||||||||
| City: | ROCKLAND | ||||||||
| State: | DE | ||||||||
| PostalCode: | 197320191 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3026516212 | ||||||||
| FaxNumber: | 3026514945 | ||||||||
| Practice Location | |||||||||
| Address1: | JEFFERSON FACULTY PEDS AND DUPONT CHILDRENS HLTH PROG | ||||||||
| Address2: | 833 CHESTNUT STREET EAST SUITE 300 | ||||||||
| City: | PHILADELPHIA | ||||||||
| State: | PA | ||||||||
| PostalCode: | 191074413 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2159557800 | ||||||||
| FaxNumber: | 2159239383 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/02/2006 | ||||||||
| LastUpdateDate: | 01/23/2012 | ||||||||
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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 | 363L00000X | UP005404N | PA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363LP0200X | UP005404N | PA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Pediatrics |
ID Information
| ID | Type | State | Issuer | Description | 4042875 | 05 | MD | MEDICAID | 0024449 | 05 | NJ | MEDICAID |