Healthcare Provider Details

I. General information

NPI: 1942696224
Provider Name (Legal Business Name): REBECCA WILSON APN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/13/2015
Last Update Date: 07/21/2020
Certification Date: 07/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2040 OGDEN AVE SUITE 215
AURORA IL
60504-7206
US

IV. Provider business mailing address

2040 OGDEN AVE STE 215
AURORA IL
60504-7205
US

V. Phone/Fax

Practice location:
  • Phone: 630-375-2844
  • Fax: 630-375-2808
Mailing address:
  • Phone: 630-375-2844
  • Fax: 630-375-2808

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209.012736
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: