Healthcare Provider Details

I. General information

NPI: 1417387119
Provider Name (Legal Business Name): RICKIE WILSON CRNA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/15/2013
Last Update Date: 11/15/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1422 E STATE ST APT # 5
ROCKFORD IL
61104-2338
US

IV. Provider business mailing address

1422 E STATE ST APT # 5
ROCKFORD IL
61104-2338
US

V. Phone/Fax

Practice location:
  • Phone: 414-702-0234
  • Fax:
Mailing address:
  • Phone: 414-702-0234
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number209.010905
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: