Healthcare Provider Details

I. General information

NPI: 1073031100
Provider Name (Legal Business Name): KATIE WILSON AGACNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/08/2017
Last Update Date: 03/05/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1900 E MAIN ST
DANVILLE IL
61832-5100
US

IV. Provider business mailing address

1900 E MAIN ST
DANVILLE IL
61832-5100
US

V. Phone/Fax

Practice location:
  • Phone: 217-554-4364
  • Fax:
Mailing address:
  • Phone: 217-554-4364
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number209.016522
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: