Healthcare Provider Details

I. General information

NPI: 1174977797
Provider Name (Legal Business Name): HEATHER WILSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/20/2016
Last Update Date: 02/01/2024
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2064 EAST SOUTH BLVD SUITE 204
MONTGOMERY AL
36116-2460
US

IV. Provider business mailing address

2064 EAST SOUTH BLVD. STE 204
MONTGOMERY AL
36116-2460
US

V. Phone/Fax

Practice location:
  • Phone: 334-281-6990
  • Fax: 334-281-9725
Mailing address:
  • Phone: 334-281-6990
  • Fax: 334-281-9725

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number1-118043
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: