Provider Demographics
NPI:1073924825
Name:WILSON, TEREASA KELLEY (CRNA)
Entity Type:Individual
Prefix:
First Name:TEREASA
Middle Name:KELLEY
Last Name:WILSON
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16901 LAKESIDE HILLS CT
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68130-2318
Mailing Address - Country:US
Mailing Address - Phone:515-991-6935
Mailing Address - Fax:
Practice Address - Street 1:700 E UNIVERSITY AVE
Practice Address - Street 2:
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50316-2302
Practice Address - Country:US
Practice Address - Phone:515-991-6935
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-14
Last Update Date:2022-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA119753163W00000X
NE101283367500000X
IAD119753367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse