Healthcare Provider Details

I. General information

NPI: 1093043168
Provider Name (Legal Business Name): EMILY DANIELLE WILSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/30/2009
Last Update Date: 11/30/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

CORNER OF SYDNEY AND LAMONT ATTN: EXTENDED CARE
MOUNTAIN HOME TN
37684
US

IV. Provider business mailing address

101 DREWTANNER LN
JOHNSON CITY TN
37604-6081
US

V. Phone/Fax

Practice location:
  • Phone: 423-926-1171
  • Fax:
Mailing address:
  • Phone: 423-794-7064
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number14272
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: