Basic Information
Provider Information | |||||||||
NPI: | 1942818729 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | WILSON | ||||||||
FirstName: | JULIE | ||||||||
MiddleName: | ANN | ||||||||
NamePrefix: | MRS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | BSN, RNFA | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 1243 LIBERTY XING | ||||||||
Address2: |   | ||||||||
City: | HERCULANEUM | ||||||||
State: | MO | ||||||||
PostalCode: | 630481733 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3147323254 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 1101 W GANNON DR | ||||||||
Address2: |   | ||||||||
City: | FESTUS | ||||||||
State: | MO | ||||||||
PostalCode: | 630282602 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6369315997 | ||||||||
FaxNumber: | 6369377968 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/17/2020 | ||||||||
LastUpdateDate: | 07/17/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 07/17/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WR0006X | 2016032691 | MO | Y |   | Nursing Service Providers | Registered Nurse | Registered Nurse First Assistant |
No ID Information.