Provider Demographics
NPI:1295209500
Name:WILSON, ANASTASIA DESIREE (APRN)
Entity Type:Individual
Prefix:
First Name:ANASTASIA
Middle Name:DESIREE
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 1:71 CRESTRIDGE DR
Mailing Address - Street 2:
Mailing Address - City:DOVER
Mailing Address - State:AR
Mailing Address - Zip Code:72837-8716
Mailing Address - Country:US
Mailing Address - Phone:479-831-9530
Mailing Address - Fax:
Practice Address - Street 1:900 W 12TH ST
Practice Address - Street 2:
Practice Address - City:RUSSELLVILLE
Practice Address - State:AR
Practice Address - Zip Code:72801-6606
Practice Address - Country:US
Practice Address - Phone:479-968-5858
Practice Address - Fax:479-890-6013
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-20
Last Update Date:2021-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA005985363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health