Basic Information
| Provider Information | |||||||||
| NPI: | 1164992939 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | WILSON | ||||||||
| FirstName: | PETRA | ||||||||
| MiddleName: | JEANNE | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 865 DANIELS FARM RD | ||||||||
| Address2: | |||||||||
| City: | TRUMBULL | ||||||||
| State: | CT | ||||||||
| PostalCode: | 066112601 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7177185778 | ||||||||
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| Practice Location | |||||||||
| Address1: | 256 SEASIDE AVE | ||||||||
| Address2: | |||||||||
| City: | MILFORD | ||||||||
| State: | CT | ||||||||
| PostalCode: | 064604602 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4758826824 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/05/2018 | ||||||||
| LastUpdateDate: | 11/13/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 7993 | CT | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.