Basic Information
| Provider Information | |||||||||
| NPI: | 1467900605 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILSON | ||||||||
| FirstName: | SKYLAR | ||||||||
| MiddleName: | FAITH | ||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | LANE | ||||||||
| OtherFirstName: | SKYLAR | ||||||||
| OtherMiddleName: | FAITH | ||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | NP-C | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 95 WALL ST | ||||||||
| Address2: | |||||||||
| City: | ALBERTVILLE | ||||||||
| State: | AL | ||||||||
| PostalCode: | 359517392 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2568783999 | ||||||||
| FaxNumber: | 2568783779 | ||||||||
| Practice Location | |||||||||
| Address1: | 2505 US HIGHWAY 431 | ||||||||
| Address2: | |||||||||
| City: | BOAZ | ||||||||
| State: | AL | ||||||||
| PostalCode: | 359575908 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2565938310 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/16/2016 | ||||||||
| LastUpdateDate: | 03/01/2017 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 1-137603 | AL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.