Healthcare Provider Details

I. General information

NPI: 1407303589
Provider Name (Legal Business Name): JENNIFER WILSON RN, FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/06/2016
Last Update Date: 10/14/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7060 WAYSIDE DR
MENTOR OH
44060-6527
US

IV. Provider business mailing address

7060 WAYSIDE DR
MENTOR OH
44060-6527
US

V. Phone/Fax

Practice location:
  • Phone: 440-357-2700
  • Fax:
Mailing address:
  • Phone: 440-357-2700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN306659
License Number StateOH
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberAPRN.CNP.020470
License Number StateOH
# 3
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberF0117825
License Number StateOH
# 4
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number020470
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: