Healthcare Provider Details

I. General information

NPI: 1003352378
Provider Name (Legal Business Name): AUDRA WILSON RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/11/2017
Last Update Date: 04/09/2025
Certification Date: 04/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3103 DIXIE HWY
HAMILTON OH
45015-1653
US

IV. Provider business mailing address

100 CROWNE POINT PL
CINCINNATI OH
45241-5427
US

V. Phone/Fax

Practice location:
  • Phone: 513-892-4673
  • Fax:
Mailing address:
  • Phone: 513-743-7628
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License NumberRN.392404
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: