Provider Demographics
NPI:1295022705
Name:WILSON, ANNIE J (APRN)
Entity Type:Individual
Prefix:
First Name:ANNIE
Middle Name:J
Last Name:WILSON
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3346 PROFESSIONAL PARK
Mailing Address - Street 2:
Mailing Address - City:OWENSBORO
Mailing Address - State:KY
Mailing Address - Zip Code:42303-4551
Mailing Address - Country:US
Mailing Address - Phone:270-852-8931
Mailing Address - Fax:270-852-8924
Practice Address - Street 1:3346 PROFESSIONAL PARK
Practice Address - Street 2:
Practice Address - City:OWENSBORO
Practice Address - State:KY
Practice Address - Zip Code:42303-4551
Practice Address - Country:US
Practice Address - Phone:270-685-1066
Practice Address - Fax:270-685-0881
Is Sole Proprietor?:No
Enumeration Date:2011-07-05
Last Update Date:2015-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3006996363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
KYP01227101OtherRAILROAD MEDICARE
KY000000818112OtherBCBS- BAPTIST HEALTH MADISONVILLE
KY7100172820Medicaid
KYP01227101OtherRAILROAD MEDICARE
KYK030906Medicare PIN