Healthcare Provider Details

I. General information

NPI: 1831731298
Provider Name (Legal Business Name): HEATHER JEAN WILSON PMHNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/16/2019
Last Update Date: 10/16/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

305 S WISE ST
PATON IA
50217-7735
US

IV. Provider business mailing address

305 S WISE ST
PATON IA
50217-7735
US

V. Phone/Fax

Practice location:
  • Phone: 515-370-4438
  • Fax:
Mailing address:
  • Phone: 515-370-4438
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0809X
TaxonomyAdult Psychiatric/Mental Health Registered Nurse
License NumberG156805
License Number StateIA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: