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General NPI Number Information
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NPI Number | 1104032218
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Entity Type | Individual
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Provider Name | LAURA RENAE WILSON MSN, APRN-BC
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Gender | Female
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Dates
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Enumeration Date | 05/15/2007
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Last Update Date | 03/06/2019
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Provider Practice Location Address
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Address Line | 5405 MEMORIAL DR STE D
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City | STONE MOUNTAIN
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State | GA
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Zip | 30083-3236
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Country | US
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Telephone | 404-296-3800
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Fax | 404-297-8753
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Provider Business Mailing Address
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Address Line | 5405 MEMORIAL DR STE D
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City | STONE MOUNTAIN
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State | GA
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Zip | 30083-3236
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Country | US
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Telephone | 404-296-3800
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Fax | 404-297-8753
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | 004365
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License Number State | CT
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Taxonomy #2
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number | 701633
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License Number State | TX
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Taxonomy #3
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Taxonomy Code | 363LP2300X
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Taxonomy Name | Primary Care Nurse Practitioner
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License Number | RN247115
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License Number State | GA
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