Healthcare Provider Details

I. General information

NPI: 1386524494
Provider Name (Legal Business Name): DARYL KAYE WILSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/08/2025
Last Update Date: 12/15/2025
Certification Date: 12/15/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10801 S SAGINAW ST STE D
GRAND BLANC MI
48439-8126
US

IV. Provider business mailing address

524 ADDISON CIR
COMMERCE TWP MI
48390-3482
US

V. Phone/Fax

Practice location:
  • Phone: 810-771-4074
  • Fax: 810-337-8103
Mailing address:
  • Phone: 602-920-4171
  • Fax: 810-337-8103

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number4704393729
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: