Provider Demographics
NPI:1073762308
Name:WILSON, JOANN MARIE (RN, APRN-BC)
Entity Type:Individual
Prefix:MRS
First Name:JOANN
Middle Name:MARIE
Last Name:WILSON
Suffix:
Gender:F
Credentials:RN, APRN-BC
Other - Prefix:MISS
Other - First Name:JOANN
Other - Middle Name:MARIE
Other - Last Name:ADAMS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:916 TALON DR
Mailing Address - Street 2:
Mailing Address - City:O FALLON
Mailing Address - State:IL
Mailing Address - Zip Code:62269-1848
Mailing Address - Country:US
Mailing Address - Phone:618-628-8211
Mailing Address - Fax:618-628-0883
Practice Address - Street 1:2023 VADALABENE DR STE 300
Practice Address - Street 2:
Practice Address - City:MARYVILLE
Practice Address - State:IL
Practice Address - Zip Code:62062-5846
Practice Address - Country:US
Practice Address - Phone:618-288-6722
Practice Address - Fax:618-288-2077
Is Sole Proprietor?:No
Enumeration Date:2008-09-10
Last Update Date:2019-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO151656363LA2200X
IL209008172363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL207465Medicare PIN