Provider Demographics
NPI:1114537222
Name:WILSON, NATALIE JOAN (CPNP)
Entity Type:Individual
Prefix:
First Name:NATALIE
Middle Name:JOAN
Last Name:WILSON
Suffix:
Gender:F
Credentials:CPNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1463 US HIGHWAY 61 STE C
Mailing Address - Street 2:
Mailing Address - City:FESTUS
Mailing Address - State:MO
Mailing Address - Zip Code:63028-4160
Mailing Address - Country:US
Mailing Address - Phone:314-596-6541
Mailing Address - Fax:636-933-2190
Practice Address - Street 1:1463 US HWY 61
Practice Address - Street 2:SUITE C
Practice Address - City:FESTUS
Practice Address - State:MO
Practice Address - Zip Code:63028-6302
Practice Address - Country:US
Practice Address - Phone:314-596-6541
Practice Address - Fax:636-933-2910
Is Sole Proprietor?:No
Enumeration Date:2020-08-04
Last Update Date:2020-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2020010590208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO2020010590OtherPNCB CERTIFICATION NUMBER
MO2013015912OtherRN