Basic Information
| Provider Information | |||||||||
| NPI: | 1609114891 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | WILSON | ||||||||
| FirstName: | SARA | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MRS. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1321 MURFREESBORO PIKE STE 702 | ||||||||
| Address2: | |||||||||
| City: | NASHVILLE | ||||||||
| State: | TN | ||||||||
| PostalCode: | 372172679 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8443597629 | ||||||||
| FaxNumber: | 6155775654 | ||||||||
| Practice Location | |||||||||
| Address1: | 721 CHUCK GRAY CT | ||||||||
| Address2: | |||||||||
| City: | OWENSBORO | ||||||||
| State: | KY | ||||||||
| PostalCode: | 42303 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2707024641 | ||||||||
| FaxNumber: | 6155775654 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/22/2013 | ||||||||
| LastUpdateDate: | 09/09/2019 | ||||||||
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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 | 171M00000X | N | Other Service Providers | Case Manager/Care Coordinator | 106S00000X | RBT-19-75804 | KY | Y |
No ID Information.