Provider Demographics
NPI:1275517864
Name:WILSON, LYNDA ELAYNE (NP)
Entity Type:Individual
Prefix:MRS
First Name:LYNDA
Middle Name:ELAYNE
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 1:113 COLORADO AVE
Mailing Address - Street 2:SUITE 105
Mailing Address - City:AMES
Mailing Address - State:IA
Mailing Address - Zip Code:50014
Mailing Address - Country:US
Mailing Address - Phone:515-292-4403
Mailing Address - Fax:515-232-8930
Practice Address - Street 1:113 COLORADO AVE
Practice Address - Street 2:SUITE 105
Practice Address - City:AMES
Practice Address - State:IA
Practice Address - Zip Code:50014
Practice Address - Country:US
Practice Address - Phone:515-292-4403
Practice Address - Fax:515-232-8930
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-12-06
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IA061661363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
52462Medicare ID - Type Unspecified