Provider Demographics
NPI:1164992939
Name:WILSON, PETRA JEANNE (NP)
Entity Type:Individual
Prefix:MRS
First Name:PETRA
Middle Name:JEANNE
Last Name:WILSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:865 DANIELS FARM RD
Mailing Address - Street 2:
Mailing Address - City:TRUMBULL
Mailing Address - State:CT
Mailing Address - Zip Code:06611-2601
Mailing Address - Country:US
Mailing Address - Phone:717-718-5778
Mailing Address - Fax:
Practice Address - Street 1:256 SEASIDE AVE
Practice Address - Street 2:
Practice Address - City:MILFORD
Practice Address - State:CT
Practice Address - Zip Code:06460-4602
Practice Address - Country:US
Practice Address - Phone:475-882-6824
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-12-05
Last Update Date:2019-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT7993363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily