Provider Demographics
NPI:1336685395
Name:WILSON, STEPHANIE LYNN (FNP-BC)
Entity Type:Individual
Prefix:MRS
First Name:STEPHANIE
Middle Name:LYNN
Last Name:WILSON
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2995 DREW ST FL 2
Mailing Address - Street 2:
Mailing Address - City:CLEARWATER
Mailing Address - State:FL
Mailing Address - Zip Code:33759-3012
Mailing Address - Country:US
Mailing Address - Phone:727-532-1355
Mailing Address - Fax:813-635-2613
Practice Address - Street 1:4211 VAN DYKE RD STE 200
Practice Address - Street 2:
Practice Address - City:LUTZ
Practice Address - State:FL
Practice Address - Zip Code:33558-8005
Practice Address - Country:US
Practice Address - Phone:813-321-6237
Practice Address - Fax:813-463-1801
Is Sole Proprietor?:No
Enumeration Date:2017-01-16
Last Update Date:2022-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL9479701363LF0000X
TNAPN0000021911363LF0000X
FLAPRN9479701363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL107548200Medicaid