Provider Demographics
NPI:1477021988
Name:WILSON, IRENE (FNP-C)
Entity Type:Individual
Prefix:
First Name:IRENE
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:IRENE
Other - Middle Name:
Other - Last Name:DIAZ
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP-C
Mailing Address - Street 1:481 CLARINGTON DR
Mailing Address - Street 2:
Mailing Address - City:SOUTHAVEN
Mailing Address - State:MS
Mailing Address - Zip Code:38671-5638
Mailing Address - Country:US
Mailing Address - Phone:901-486-0439
Mailing Address - Fax:
Practice Address - Street 1:75 PHYSICIANS LN
Practice Address - Street 2:
Practice Address - City:SOUTHAVEN
Practice Address - State:MS
Practice Address - Zip Code:38671-6102
Practice Address - Country:US
Practice Address - Phone:662-393-7722
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-11-02
Last Update Date:2018-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS902979363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care