Provider Demographics
NPI:1407598204
Name:WILSON, CHERYL (FNP-BC)
Entity Type:Individual
Prefix:
First Name:CHERYL
Middle Name:
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 1:3533 WYOMING ST
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63118-2020
Mailing Address - Country:US
Mailing Address - Phone:314-479-3545
Mailing Address - Fax:
Practice Address - Street 1:3533 WYOMING ST
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63118-2020
Practice Address - Country:US
Practice Address - Phone:314-479-3545
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-12
Last Update Date:2022-04-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2022012515363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily