Healthcare Provider Details

I. General information

NPI: 1457104564
Provider Name (Legal Business Name): RAQUEL WILSON PMHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/09/2024
Last Update Date: 09/16/2026
Certification Date: 09/16/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

309 N 5TH ST
WEST MEMPHIS AR
72301-3213
US

IV. Provider business mailing address

1500 OAKLAWN DR
WEST MEMPHIS AR
72301-2996
US

V. Phone/Fax

Practice location:
  • Phone: 870-260-7902
  • Fax:
Mailing address:
  • Phone: 870-260-7902
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number228158
License Number StateAR
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberR08131
License Number StateAR
# 3
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number927570
License Number StateTX
# 4
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number36872
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: