Provider Demographics
NPI:1407403348
Name:WILSON, COURTNEY NICOLE (NP)
Entity Type:Individual
Prefix:
First Name:COURTNEY
Middle Name:NICOLE
Last Name:WILSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 735379
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60673-5379
Mailing Address - Country:US
Mailing Address - Phone:563-340-3782
Mailing Address - Fax:563-204-4474
Practice Address - Street 1:1130 W 53RD ST
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:IA
Practice Address - Zip Code:52806-2401
Practice Address - Country:US
Practice Address - Phone:563-340-3782
Practice Address - Fax:563-204-4474
Is Sole Proprietor?:No
Enumeration Date:2019-08-26
Last Update Date:2024-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.020089363LF0000X
IAA155984363LF0000X
IA136561163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse