Provider Demographics
NPI:1417387119
Name:WILSON, RICKIE (CRNA)
Entity Type:Individual
Prefix:
First Name:RICKIE
Middle Name:
Last Name:WILSON
Suffix:
Gender:M
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1422 E STATE ST
Mailing Address - Street 2:APT # 5
Mailing Address - City:ROCKFORD
Mailing Address - State:IL
Mailing Address - Zip Code:61104-2338
Mailing Address - Country:US
Mailing Address - Phone:414-702-0234
Mailing Address - Fax:
Practice Address - Street 1:1422 E STATE ST
Practice Address - Street 2:APT # 5
Practice Address - City:ROCKFORD
Practice Address - State:IL
Practice Address - Zip Code:61104-2338
Practice Address - Country:US
Practice Address - Phone:414-702-0234
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-15
Last Update Date:2013-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209.010905367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered