Basic Information
| Provider Information | |||||||||
| NPI: | 1215997028 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILSON | ||||||||
| FirstName: | CANDICE | ||||||||
| MiddleName: | LYNN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | M.D. | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 11105 | ||||||||
| Address2: | |||||||||
| City: | KNOXVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 379391105 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8655882928 | ||||||||
| FaxNumber: | 8654509374 | ||||||||
| Practice Location | |||||||||
| Address1: | 990 OAK RIDGE TPKE | ||||||||
| Address2: | |||||||||
| City: | OAK RIDGE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 378306976 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8658354600 | ||||||||
| FaxNumber: | 8658354609 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/24/2006 | ||||||||
| LastUpdateDate: | 07/24/2008 | ||||||||
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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 | 174400000X | ME94386 | FL | N | Other Service Providers | Specialist | 174400000X | 0000037867 | TN | Y | Other Service Providers | Specialist | 174400000X | 055042 | GA | N | Other Service Providers | Specialist | 174400000X | 00027018 | AL | N | Other Service Providers | Specialist |
ID Information
| ID | Type | State | Issuer | Description | 1882432 | 01 | TN | FIRST HEALTH | OTHER | 807388100 | 05 | GA | MEDICAID | 9495633 | 01 | TN | CIGNA | OTHER | 7100041970 | 05 | KY | MEDICAID | 4184755 | 01 | TN | BCBS OF TN | OTHER |