Provider Demographics
NPI:1073031100
Name:WILSON, KATIE (AGACNP-BC)
Entity Type:Individual
Prefix:
First Name:KATIE
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:AGACNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1900 E MAIN ST
Mailing Address - Street 2:
Mailing Address - City:DANVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:61832-5100
Mailing Address - Country:US
Mailing Address - Phone:217-554-4364
Mailing Address - Fax:
Practice Address - Street 1:1900 E MAIN ST
Practice Address - Street 2:
Practice Address - City:DANVILLE
Practice Address - State:IL
Practice Address - Zip Code:61832-5100
Practice Address - Country:US
Practice Address - Phone:217-554-4364
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-08
Last Update Date:2019-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.016522363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology