Healthcare Provider Details

I. General information

NPI: 1336479161
Provider Name (Legal Business Name): STEPHANIE S WILSON NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/29/2009
Last Update Date: 04/24/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2009 BROWN ST
ANDERSON IN
46016-4216
US

IV. Provider business mailing address

9615 E 148TH ST SUITE 1
NOBLESVILLE IN
46060-4360
US

V. Phone/Fax

Practice location:
  • Phone: 317-574-1254
  • Fax: 317-674-0060
Mailing address:
  • Phone: 317-587-0500
  • Fax: 317-674-0060

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number28144253A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: