MEDICARE: STACEY LYNN 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	2017006269	AR

General Provider Information

NPI Number	:	1760911176
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	STACEY LYNN WILSON FNP-BC

Provider Business Mailing Address
First Line	:	226 MADISON 7875
Second Line	:
City	:	WESLEY
State	:	AR
Zip	:	72773-8615
Country	:	US
Telephone Number	:	479-790-9308
Fax Number	:

Provider Business Practice Location Address
First Line	:	226 MADISON 7875
Second Line	:
City	:	WESLEY
State	:	AR
Zip	:	72773
Country	:	US
Telephone Number	:	479-790-9308
Fax Number	:

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

Provider Enumeration Date	:	06/08/2017
Last Update Date	:	07/21/2022

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