Healthcare Provider Details

I. General information

NPI: 1255625216
Provider Name (Legal Business Name): HEATHER LYNNE WILSON APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: HEATHER LYNNE ROSE

II. Dates (important events)

Enumeration Date: 06/07/2011
Last Update Date: 02/09/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

85 SEYMOUR ST SUITE 900
HARTFORD CT
06106-5501
US

IV. Provider business mailing address

2110 SILAS DEANE HWY
ROCKY HILL CT
06067-2313
US

V. Phone/Fax

Practice location:
  • Phone: 860-241-0700
  • Fax: 860-525-7881
Mailing address:
  • Phone: 860-258-3470
  • Fax: 860-571-6800

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number004730
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number004730
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: