MEDICARE: MRS. ELLA NORA WILSON FNP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	209-006175	IL

General Provider Information

NPI Number	:	1275600702
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. ELLA NORA WILSON FNP

Provider Business Mailing Address
First Line	:	706 E BRIDGEPORT ST
Second Line	:
City	:	OKAWVILLE
State	:	IL
Zip	:	62271-1156
Country	:	US
Telephone Number	:	618-314-2696
Fax Number	:

Provider Business Practice Location Address
First Line	:	12 N 64TH ST
Second Line	:
City	:	BELLEVILLE
State	:	IL
Zip	:	62223-3809
Country	:	US
Telephone Number	:	618-877-4420
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/29/2006
Last Update Date	:	08/02/2013

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