Provider Demographics
NPI:1467653014
Name:WILSON, RENEE D (RNP)
Entity Type:Individual
Prefix:MS
First Name:RENEE
Middle Name:D
Last Name:WILSON
Suffix:
Gender:F
Credentials:RNP
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 1270
Mailing Address - Street 2:
Mailing Address - City:BENTON
Mailing Address - State:AR
Mailing Address - Zip Code:72018-1270
Mailing Address - Country:US
Mailing Address - Phone:501-317-6996
Mailing Address - Fax:
Practice Address - Street 1:825 GRAHAM RD
Practice Address - Street 2:
Practice Address - City:BENTON
Practice Address - State:AR
Practice Address - Zip Code:72015-8975
Practice Address - Country:US
Practice Address - Phone:501-317-6996
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-05-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARP00903363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner