Provider Demographics
NPI:1174499867
Name:WILSON, THERESA
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11124 KINGSTON PIKE
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37934-2863
Mailing Address - Country:US
Mailing Address - Phone:720-227-3491
Mailing Address - Fax:
Practice Address - Street 1:11608 BOSTON IVY LN
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37932-1005
Practice Address - Country:US
Practice Address - Phone:720-227-3491
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-10-11
Last Update Date:2025-10-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN232971163WX1500X, 163WW0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163WW0000XNursing Service ProvidersRegistered NurseWound CareGroup - Multi-Specialty
No163WX1500XNursing Service ProvidersRegistered NurseOstomy CareGroup - Multi-Specialty