Provider Demographics
NPI:1033494794
Name:WILSON, MANDY CORINNE (NP)
Entity Type:Individual
Prefix:
First Name:MANDY
Middle Name:CORINNE
Last Name:WILSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:MANDY
Other - Middle Name:CORINNE
Other - Last Name:LEAHIGH
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 3395
Mailing Address - Street 2:
Mailing Address - City:EVANSVILLE
Mailing Address - State:IN
Mailing Address - Zip Code:47732-3395
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1373 E STATE ROAD 62
Practice Address - Street 2:
Practice Address - City:MADISON
Practice Address - State:IN
Practice Address - Zip Code:47250-7328
Practice Address - Country:US
Practice Address - Phone:812-801-0868
Practice Address - Fax:812-801-8070
Is Sole Proprietor?:No
Enumeration Date:2011-10-13
Last Update Date:2024-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71003745A363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100314430Medicaid
IN9610899OtherAETNA
IN201085400Medicaid
IN897443OtherANTHEM