MEDICARE: NICOLE Q WILSON A.P.N,

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	277.000623	IL

General Provider Information

NPI Number	:	1972056109
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NICOLE Q WILSON A.P.N,

Provider Business Mailing Address
First Line	:	2200 E 93RD ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60617-3905
Country	:	US
Telephone Number	:	773-530-7356
Fax Number	:

Provider Business Practice Location Address
First Line	:	2200 E 93RD ST
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60617-3905
Country	:	US
Telephone Number	:	773-530-7356
Fax Number	:

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

Provider Enumeration Date	:	07/23/2016
Last Update Date	:	12/08/2025

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