Provider Demographics
NPI:1164523403
Name:WILSON, DONNA C (FNP)
Entity Type:Individual
Prefix:
First Name:DONNA
Middle Name:C
Last Name:WILSON
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:DONNA
Other - Middle Name:C
Other - Last Name:GASS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 4046
Mailing Address - Street 2:
Mailing Address - City:SPRINGFIELD
Mailing Address - State:MO
Mailing Address - Zip Code:65808-4046
Mailing Address - Country:US
Mailing Address - Phone:417-269-5712
Mailing Address - Fax:417-269-7567
Practice Address - Street 1:510 HIGHWAY 32
Practice Address - Street 2:
Practice Address - City:LEBANON
Practice Address - State:MO
Practice Address - Zip Code:65536-5303
Practice Address - Country:US
Practice Address - Phone:417-269-2278
Practice Address - Fax:417-269-2274
Is Sole Proprietor?:No
Enumeration Date:2006-09-26
Last Update Date:2019-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO076398363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO428372809Medicaid
190892OtherBLUE CROSS OF MO
MOP00450602Medicare PIN
P84302Medicare UPIN
190892OtherBLUE CROSS OF MO