Healthcare Provider Details

I. General information

NPI: 1922026731
Provider Name (Legal Business Name): CAROL J WILSON PNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2006
Last Update Date: 12/28/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

660 S EUCLID AVE
SAINT LOUIS MO
63110-1010
US

IV. Provider business mailing address

PO BOX 8221 7425 FORSYTH
SAINT LOUIS MO
63156-8221
US

V. Phone/Fax

Practice location:
  • Phone: 314-454-6051
  • Fax: 314-454-4801
Mailing address:
  • Phone: 314-454-6051
  • Fax: 314-454-4801

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number048768
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: