Provider Demographics
NPI:1346250586
Name:WILTON, JEANNE (WHNP-BC)
Entity Type:Individual
Prefix:
First Name:JEANNE
Middle Name:
Last Name:WILTON
Suffix:
Gender:F
Credentials:WHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1716 HARTFORD STREET
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47904-2138
Mailing Address - Country:US
Mailing Address - Phone:765-742-1567
Mailing Address - Fax:
Practice Address - Street 1:2316 SOUTH STREET
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47904-2971
Practice Address - Country:US
Practice Address - Phone:765-742-1567
Practice Address - Fax:765-429-2700
Is Sole Proprietor?:No
Enumeration Date:2006-08-09
Last Update Date:2022-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71004828A363L00000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201217180Medicaid