Healthcare Provider Details

I. General information

NPI: 1356402242
Provider Name (Legal Business Name): THERESA WILSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/13/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1101 HOSPITAL DR
COLUMBIA MO
65212-0001
US

IV. Provider business mailing address

1101 HOSPITAL DR
COLUMBIA MO
65212-0001
US

V. Phone/Fax

Practice location:
  • Phone: 573-882-7481
  • Fax:
Mailing address:
  • Phone: 573-882-7481
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WC1400X
TaxonomyCollege Health Registered Nurse
License Number60883
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: