Healthcare Provider Details

I. General information

NPI: 1114537222
Provider Name (Legal Business Name): NATALIE JOAN WILSON CPNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/04/2020
Last Update Date: 08/04/2020
Certification Date: 08/04/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1463 US HWY 61 SUITE C
FESTUS MO
63028-6302
US

IV. Provider business mailing address

1463 US HIGHWAY 61 STE C
FESTUS MO
63028-4160
US

V. Phone/Fax

Practice location:
  • Phone: 314-596-6541
  • Fax: 636-933-2910
Mailing address:
  • Phone: 314-596-6541
  • Fax: 636-933-2190

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208000000X
TaxonomyPediatrics Physician
License Number2020010590
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: