Provider Demographics
NPI:1225027832
Name:WILSON, CHARLA F (FNP)
Entity Type:Individual
Prefix:
First Name:CHARLA
Middle Name:F
Last Name:WILSON
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6248 CAROLOT LN
Mailing Address - Street 2:
Mailing Address - City:BARTLETT
Mailing Address - State:TN
Mailing Address - Zip Code:38135-1196
Mailing Address - Country:US
Mailing Address - Phone:901-372-8486
Mailing Address - Fax:
Practice Address - Street 1:9075 SANDIDGE CENTER COVE
Practice Address - Street 2:
Practice Address - City:OLIVE BRANCH
Practice Address - State:MS
Practice Address - Zip Code:38654
Practice Address - Country:US
Practice Address - Phone:662-895-4949
Practice Address - Fax:662-895-6746
Is Sole Proprietor?:No
Enumeration Date:2005-10-17
Last Update Date:2018-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN5158363LF0000X
MSR844603207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
TNP37122Medicare UPIN