Healthcare Provider Details

I. General information

NPI: 1710307889
Provider Name (Legal Business Name): LISA RUTH WILSON AGNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/16/2014
Last Update Date: 04/16/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

324 W 5TH ST
WASHINGTON MO
63090-2306
US

IV. Provider business mailing address

24776 STATE HIGHWAY EE
WARRENTON MO
63383-5883
US

V. Phone/Fax

Practice location:
  • Phone: 636-795-0342
  • Fax:
Mailing address:
  • Phone: 636-795-0342
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number2014010130
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: