MEDICARE: LAURA ANN WILSON FNP-C

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	209026113	IL

General Provider Information

NPI Number	:	1710604780
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LAURA ANN WILSON FNP-C

Provider Business Mailing Address
First Line	:	1130 JACOB DR
Second Line	:
City	:	RED BUD
State	:	IL
Zip	:	62278-2433
Country	:	US
Telephone Number	:	618-719-4939
Fax Number	:

Provider Business Practice Location Address
First Line	:	1215 VANDALIA ST
Second Line	:
City	:	COLLINSVILLE
State	:	IL
Zip	:	62234-4060
Country	:	US
Telephone Number	:	618-343-6015
Fax Number	:

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

Provider Enumeration Date	:	10/20/2022
Last Update Date	:	12/24/2025

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