Provider Demographics
NPI:1104032218
Name:WILSON, LAURA RENAE (MSN, APRN-BC)
Entity Type:Individual
Prefix:MRS
First Name:LAURA
Middle Name:RENAE
Last Name:WILSON
Suffix:
Gender:F
Credentials:MSN, APRN-BC
Other - Prefix:MISS
Other - First Name:LAURA
Other - Middle Name:RENAE
Other - Last Name:PHELPS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSN, APRN-BC
Mailing Address - Street 1:5405 MEMORIAL DR STE D
Mailing Address - Street 2:
Mailing Address - City:STONE MOUNTAIN
Mailing Address - State:GA
Mailing Address - Zip Code:30083-3236
Mailing Address - Country:US
Mailing Address - Phone:404-296-3800
Mailing Address - Fax:404-297-8753
Practice Address - Street 1:5405 MEMORIAL DR STE D
Practice Address - Street 2:
Practice Address - City:STONE MOUNTAIN
Practice Address - State:GA
Practice Address - Zip Code:30083-3236
Practice Address - Country:US
Practice Address - Phone:404-296-3800
Practice Address - Fax:404-297-8753
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-15
Last Update Date:2019-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT004365363LF0000X
TX701633363LF0000X
GARN247115363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1821185299OtherNPI - BVCAA
TX1275620551OtherNPI - ROBERTSON COUNTY CHC
TX154467803Medicaid
TX1649265646OtherNPI- BRYAN- COLLEGE STATION CHC
TX154467803Medicaid