Healthcare Provider Details

I. General information

NPI: 1417648148
Provider Name (Legal Business Name): CAWONDA RANEE WILSON PMHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/15/2023
Last Update Date: 05/02/2024
Certification Date: 05/02/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2501 CHATHAM RD
SPRINGFIELD IL
62704-4188
US

IV. Provider business mailing address

6823 SUSSEX RD
TINLEY PARK IL
60477-1745
US

V. Phone/Fax

Practice location:
  • Phone: 253-922-4027
  • Fax: 844-222-0800
Mailing address:
  • Phone: 708-682-4748
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number209027707
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number2023032312
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number2023032312
License Number StateIL
# 4
Primary TaxonomyN
Taxonomy Code2084P0805X
TaxonomyGeriatric Psychiatry Physician
License Number041469714
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: