MEDICARE: MRS. CHERIE MICHELLE WILSON FNP

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	71002297A	IN
2	363LF0000X	Family Nurse Practitioner	4704254611	MI

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	71002297A	OTHER	IN	STATE LICENSE
2	4704254611	OTHER	MI	FAMILY NURSE PRACTITIONER

General Provider Information

NPI Number	:	1598833279
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. CHERIE MICHELLE WILSON FNP

Provider Business Mailing Address
First Line	:	9045 US HIGHWAY 31
Second Line	:
City	:	BERRIEN SPRINGS
State	:	MI
Zip	:	49103-1804
Country	:	US
Telephone Number	:	269-473-2222
Fax Number	:	269-473-6880

Provider Business Practice Location Address
First Line	:	9045 US HIGHWAY 31
Second Line	:
City	:	BERRIEN SPRINGS
State	:	MI
Zip	:	49103-1804
Country	:	US
Telephone Number	:	269-473-2222
Fax Number	:	269-473-6880

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

Provider Enumeration Date	:	12/01/2006
Last Update Date	:	02/20/2008

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