Provider Demographics
NPI:1073146874
Name:WILSON, AUDRA (MS, RDN)
Entity Type:Individual
Prefix:
First Name:AUDRA
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:MS, RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1217 RITA AVE
Mailing Address - Street 2:
Mailing Address - City:SAINT CHARLES
Mailing Address - State:IL
Mailing Address - Zip Code:60174-4441
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:300 RANDALL RD STE 100
Practice Address - Street 2:
Practice Address - City:GENEVA
Practice Address - State:IL
Practice Address - Zip Code:60134-4200
Practice Address - Country:US
Practice Address - Phone:630-933-3513
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-20
Last Update Date:2020-02-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL164006665