Provider Demographics
NPI:1093869380
Name:WILSON, MARY MICHELLE (MSN, ARNP, FNP-BC)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:MICHELLE
Last Name:WILSON
Suffix:
Gender:F
Credentials:MSN, ARNP, FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1021 NEBRASKA ST
Mailing Address - Street 2:
Mailing Address - City:SIOUX CITY
Mailing Address - State:IA
Mailing Address - Zip Code:51104-5410
Mailing Address - Country:US
Mailing Address - Phone:712-252-2247
Mailing Address - Fax:712-252-5516
Practice Address - Street 1:1021 NEBRASKA ST
Practice Address - Street 2:
Practice Address - City:SIOUX CITY
Practice Address - State:IA
Practice Address - Zip Code:51104-5410
Practice Address - Country:US
Practice Address - Phone:712-252-2247
Practice Address - Fax:712-252-5516
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-23
Last Update Date:2011-09-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAA-099445363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily