Basic Information
| Provider Information | |||||||||
| NPI: | 1255870465 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILSON | ||||||||
| FirstName: | VALERIE | ||||||||
| MiddleName: | RACHELLE | ||||||||
| NamePrefix: | DR. | ||||||||
| NameSuffix: | |||||||||
| Credential: | DNP, FNP-C | ||||||||
| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 350 S 40TH ST | ||||||||
| Address2: | |||||||||
| City: | MUSKOGEE | ||||||||
| State: | OK | ||||||||
| PostalCode: | 744014915 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9186830753 | ||||||||
| FaxNumber: | 9186835677 | ||||||||
| Practice Location | |||||||||
| Address1: | 6633 E 540 RD | ||||||||
| Address2: | |||||||||
| City: | CLAREMORE | ||||||||
| State: | OK | ||||||||
| PostalCode: | 74019 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9189650220 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/21/2017 | ||||||||
| LastUpdateDate: | 12/15/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 12/14/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WG0000X | 95796 | OK | N | Nursing Service Providers | Registered Nurse | General Practice | 207Q00000X | F09171417 | OK | N | Allopathic & Osteopathic Physicians | Family Medicine | 207Q00000X | 95796 | OK | Y | Allopathic & Osteopathic Physicians | Family Medicine |
ID Information
| ID | Type | State | Issuer | Description | 95796 | 01 | RN | OTHER | F09171417 | 01 | OK | NP-C | OTHER | 1255870465 | 05 | OK | MEDICAID |