Healthcare Provider Details

I. General information

NPI: 1467058420
Provider Name (Legal Business Name): STACI ERICA WILSON RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/07/2020
Last Update Date: 12/07/2020
Certification Date: 12/07/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1602 SKIPWITH RD
RICHMOND VA
23229-5205
US

IV. Provider business mailing address

2005 AIRY CIR
HENRICO VA
23238-3274
US

V. Phone/Fax

Practice location:
  • Phone: 804-289-4500
  • Fax:
Mailing address:
  • Phone: 214-354-6170
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WC0200X
TaxonomyCritical Care Medicine Registered Nurse
License Number0001243128
License Number StateVA
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number0001243128
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: