Provider Demographics
NPI:1396207353
Name:WILSON, JOYCELYN AMPON (CRNA)
Entity Type:Individual
Prefix:MRS
First Name:JOYCELYN
Middle Name:AMPON
Last Name:WILSON
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:MISS
Other - First Name:JOYCELYN
Other - Middle Name:COBRADOR
Other - Last Name:AMPON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:4401 PARK GLEN RD APT 301
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55416-4767
Mailing Address - Country:US
Mailing Address - Phone:808-352-7728
Mailing Address - Fax:
Practice Address - Street 1:333 SMITH AVE N
Practice Address - Street 2:
Practice Address - City:SAINT PAUL
Practice Address - State:MN
Practice Address - Zip Code:55102-2344
Practice Address - Country:US
Practice Address - Phone:651-241-8000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-04-01
Last Update Date:2019-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN2208091367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
122707OtherNBCRNA CREDENTIAL ID
MN2208091OtherMINNESOTA RN LICENSE NUMBER