Provider Demographics
NPI:1417495672
Name:WILSON, LYNDSEY
Entity Type:Individual
Prefix:
First Name:LYNDSEY
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:
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 1329
Mailing Address - Street 2:
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IN
Mailing Address - Zip Code:47402-1329
Mailing Address - Country:US
Mailing Address - Phone:812-829-2237
Mailing Address - Fax:812-829-6342
Practice Address - Street 1:9 N CRANE AVE
Practice Address - Street 2:
Practice Address - City:SPENCER
Practice Address - State:IN
Practice Address - Zip Code:47460-1507
Practice Address - Country:US
Practice Address - Phone:812-829-2237
Practice Address - Fax:812-829-6342
Is Sole Proprietor?:No
Enumeration Date:2017-02-08
Last Update Date:2020-12-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71006887A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily