Provider Demographics
NPI:1164609350
Name:WILSON, NANNETTE G (ARNP)
Entity Type:Individual
Prefix:MS
First Name:NANNETTE
Middle Name:G
Last Name:WILSON
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1200 EDGEWATER DR
Mailing Address - Street 2:
Mailing Address - City:ORLANDO
Mailing Address - State:FL
Mailing Address - Zip Code:32804-6314
Mailing Address - Country:US
Mailing Address - Phone:407-244-8559
Mailing Address - Fax:407-218-4563
Practice Address - Street 1:1200 EDGEWATER DR
Practice Address - Street 2:
Practice Address - City:ORLANDO
Practice Address - State:FL
Practice Address - Zip Code:32804-6314
Practice Address - Country:US
Practice Address - Phone:407-244-8559
Practice Address - Fax:407-218-4563
Is Sole Proprietor?:Yes
Enumeration Date:2008-01-30
Last Update Date:2013-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL1520302363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLFC200ZMedicare UPIN