MEDICARE: CHERYL WILSON FNP-BC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	2022012515	MO

General Provider Information

NPI Number	:	1407598204
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CHERYL WILSON FNP-BC

Provider Business Mailing Address
First Line	:	3533 WYOMING ST
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63118-2020
Country	:	US
Telephone Number	:	314-479-3545
Fax Number	:

Provider Business Practice Location Address
First Line	:	3533 WYOMING ST
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63118-2020
Country	:	US
Telephone Number	:	314-479-3545
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	04/12/2022
Last Update Date	:	04/12/2022

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