Healthcare Provider Details

I. General information

NPI: 1639546047
Provider Name (Legal Business Name): MAUREEN ELISABETH WILSON APN, CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/01/2015
Last Update Date: 05/06/2026
Certification Date: 05/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1401 EASTLAND DR
BLOOMINGTON IL
61701-3552
US

IV. Provider business mailing address

101 W UNIVERSITY AVE
CHAMPAIGN IL
61820-3981
US

V. Phone/Fax

Practice location:
  • Phone: 309-663-8311
  • Fax: 309-661-3390
Mailing address:
  • Phone: 309-663-8311
  • Fax: 309-661-3390

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number209.013240
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: