Basic Information
| Provider Information | |||||||||
| NPI: | 1467604306 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILSON | ||||||||
| FirstName: | JULIE | ||||||||
| MiddleName: | DIANE | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Credential: | APRN | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 8577 | ||||||||
| Address2: | |||||||||
| City: | OMAHA | ||||||||
| State: | NE | ||||||||
| PostalCode: | 68108 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4023977057 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 10707 PACIFIC ST | ||||||||
| Address2: | SUITE 101 | ||||||||
| City: | OMAHA | ||||||||
| State: | NE | ||||||||
| PostalCode: | 68114 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4023977989 | ||||||||
| FaxNumber: | 4023937554 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/22/2008 | ||||||||
| LastUpdateDate: | 06/19/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 110989 | NE | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | 363L00000X | H-120818 | IA | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.