Provider Demographics
NPI:1033202452
Name:WILSON, RENEE PROCTOR (NP)
Entity Type:Individual
Prefix:MRS
First Name:RENEE
Middle Name:PROCTOR
Last Name:WILSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:585 N 500 W
Mailing Address - Street 2:
Mailing Address - City:PROVO
Mailing Address - State:UT
Mailing Address - Zip Code:84601-1548
Mailing Address - Country:US
Mailing Address - Phone:801-404-5588
Mailing Address - Fax:801-216-8357
Practice Address - Street 1:585 N 500 W
Practice Address - Street 2:
Practice Address - City:PROVO
Practice Address - State:UT
Practice Address - Zip Code:84601-1548
Practice Address - Country:US
Practice Address - Phone:801-404-5588
Practice Address - Fax:801-216-8357
Is Sole Proprietor?:No
Enumeration Date:2006-09-30
Last Update Date:2021-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT9867259367A00000X
CANP16867363L00000X
OR201508621NP-PP363LF0000X
CA16867363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
CARN540364Medicaid
CAZZZ05405ZMedicare PIN
CAAQ572ZMedicare PIN
Q77554Medicare UPIN