Provider Demographics
NPI:1275508616
Name:WILSON, LULA C (CFNP)
Entity Type:Individual
Prefix:
First Name:LULA
Middle Name:C
Last Name:WILSON
Suffix:
Gender:F
Credentials:CFNP
Other - Prefix:
Other - First Name:CONNIE
Other - Middle Name:B
Other - Last Name:WILSON
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:CFNP
Mailing Address - Street 1:107 BRANDON RD
Mailing Address - Street 2:
Mailing Address - City:STARKVILLE
Mailing Address - State:MS
Mailing Address - Zip Code:39759-2521
Mailing Address - Country:US
Mailing Address - Phone:662-324-1291
Mailing Address - Fax:662-324-2196
Practice Address - Street 1:107 BRANDON RD
Practice Address - Street 2:
Practice Address - City:STARKVILLE
Practice Address - State:MS
Practice Address - Zip Code:39759-2521
Practice Address - Country:US
Practice Address - Phone:662-324-1291
Practice Address - Fax:662-324-2196
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR640514363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSS97051Medicare UPIN