Healthcare Provider Details

I. General information

NPI: 1912369182
Provider Name (Legal Business Name): JOHNNA MCKELVEY WILSON D.O.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: JOHNNA MCKELVEY SIZEMORE

II. Dates (important events)

Enumeration Date: 03/25/2016
Last Update Date: 09/08/2025
Certification Date: 09/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4011 GATEWAY BLVD
NEWBURGH IN
47630-8947
US

IV. Provider business mailing address

PO BOX 632281
CINCINNATI OH
45263-2281
US

V. Phone/Fax

Practice location:
  • Phone: 812-842-3880
  • Fax: 812-842-3916
Mailing address:
  • Phone: 812-450-6815
  • Fax: 812-450-6822

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2080P0203X
TaxonomyPediatric Critical Care Medicine Physician
License Number02007225A
License Number StateIN
# 2
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number125.068895
License Number StateIL
# 3
Primary TaxonomyN
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number036148541
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: