Provider Demographics
NPI:1417648148
Name:WILSON, CAWONDA RANEE (PMHNP-BC)
Entity Type:Individual
Prefix:
First Name:CAWONDA
Middle Name:RANEE
Last Name:WILSON
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6823 SUSSEX RD
Mailing Address - Street 2:
Mailing Address - City:TINLEY PARK
Mailing Address - State:IL
Mailing Address - Zip Code:60477-1745
Mailing Address - Country:US
Mailing Address - Phone:708-682-4748
Mailing Address - Fax:
Practice Address - Street 1:2501 CHATHAM RD
Practice Address - Street 2:
Practice Address - City:SPRINGFIELD
Practice Address - State:IL
Practice Address - Zip Code:62704-4188
Practice Address - Country:US
Practice Address - Phone:253-922-4027
Practice Address - Fax:844-222-0800
Is Sole Proprietor?:No
Enumeration Date:2023-05-15
Last Update Date:2024-01-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL20230323122084P0800X, 363LP0808X
IL0414697142084P0805X
IL209027707363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No2084P0800XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyPsychiatry
No2084P0805XAllopathic & Osteopathic PhysiciansPsychiatry & NeurologyGeriatric Psychiatry
No363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL209027707OtherADVANCED NURSE PRACTITIONER