Healthcare Provider Details

I. General information

NPI: 1457954398
Provider Name (Legal Business Name): DOLORES JOSEPHINE WILSON APRN, FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: DOLORES J WILSON

II. Dates (important events)

Enumeration Date: 11/20/2020
Last Update Date: 11/05/2024
Certification Date: 11/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

211 S WALNUT ST
ARTHUR IL
61911-1269
US

IV. Provider business mailing address

PO BOX 372
MATTOON IL
61938-0372
US

V. Phone/Fax

Practice location:
  • Phone: 217-543-3444
  • Fax: 217-543-3751
Mailing address:
  • Phone: 217-868-2812
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209021427
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: