Healthcare Provider Details

I. General information

NPI: 1447162102
Provider Name (Legal Business Name): PAMELA A WILSON MSN, APRN, FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/18/2026
Last Update Date: 09/18/2026
Certification Date: 09/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

302 KAKI ST
IUKA MS
38852-1117
US

IV. Provider business mailing address

302 KAKI ST
IUKA MS
38852-1117
US

V. Phone/Fax

Practice location:
  • Phone: 662-423-3662
  • Fax: 662-200-5958
Mailing address:
  • Phone: 662-423-9229
  • Fax: 662-200-5958

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number908604
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: