Healthcare Provider Details

I. General information

NPI: 1952535171
Provider Name (Legal Business Name): NICOLE DENISE WILSON APN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/04/2009
Last Update Date: 08/26/2024
Certification Date: 08/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

765 FLORENCE RD
SAVANNAH TN
38372-3451
US

IV. Provider business mailing address

PO BOX 655
SAVANNAH TN
38372-0655
US

V. Phone/Fax

Practice location:
  • Phone: 731-925-2300
  • Fax:
Mailing address:
  • Phone: 731-925-2300
  • Fax: 731-925-2157

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number14149
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: