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General NPI Number Information
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NPI Number | 1417387119
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Entity Type | Individual
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Provider Name | RICKIE WILSON CRNA
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Gender | Male
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Dates
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Enumeration Date | 11/15/2013
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Last Update Date | 11/15/2013
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Provider Practice Location Address
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Address Line | 1422 E STATE ST APT # 5
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City | ROCKFORD
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State | IL
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Zip | 61104-2338
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Country | US
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Telephone | 414-702-0234
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Fax |
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Provider Business Mailing Address
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Address Line | 1422 E STATE ST APT # 5
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City | ROCKFORD
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State | IL
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Zip | 61104-2338
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Country | US
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Telephone | 414-702-0234
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Fax |
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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 | 367500000X
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Taxonomy Name | Certified Registered Nurse Anesthetist
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License Number | 209.010905
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License Number State | IL
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