Healthcare Provider Details

I. General information

NPI: 1073762308
Provider Name (Legal Business Name): JOANN M WILSON AGNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/10/2008
Last Update Date: 08/19/2026
Certification Date: 07/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4921 PARKVIEW PL DEPT ANESTHESIOLOGY, STE 14C
SAINT LOUIS MO
63110-1032
US

IV. Provider business mailing address

PO BOX 7412011
CHICAGO IL
60674-2011
US

V. Phone/Fax

Practice location:
  • Phone: 314-362-8820
  • Fax: 314-747-2173
Mailing address:
  • Phone: 314-362-8820
  • Fax: 314-747-2173

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number151656
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: