Healthcare Provider Details

I. General information

NPI: 1215997028
Provider Name (Legal Business Name): CANDICE LYNN WILSON M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/24/2006
Last Update Date: 12/04/2025
Certification Date: 12/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1521 DOWNTOWN WEST BLVD
KNOXVILLE TN
37919-5407
US

IV. Provider business mailing address

JHQMC MOUNTAIN HOME VA; RADIOLOGY DEPARTMENT PO BOX 4000
MOUNTAIN HOME TN
37684-4000
US

V. Phone/Fax

Practice location:
  • Phone: 865-545-4592
  • Fax: 865-693-8978
Mailing address:
  • Phone: 423-926-1171
  • Fax: 429-979-3470

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License NumberME94386
License Number StateFL
# 2
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number055042
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number0000037867
License Number StateTN
# 4
Primary TaxonomyY
Taxonomy Code2085R0202X
TaxonomyDiagnostic Radiology Physician
License Number0000037867
License Number StateTN
# 5
Primary TaxonomyN
Taxonomy Code174400000X
TaxonomySpecialist
License Number00027018
License Number StateAL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: