Provider Demographics
NPI:1508137894
Name:WILSON, DIANA LEE (PMHNP-BC)
Entity Type:Individual
Prefix:MRS
First Name:DIANA
Middle Name:LEE
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 1:550 OSBORN BLVD STE 1006
Mailing Address - Street 2:
Mailing Address - City:SAULT SAINTE MARIE
Mailing Address - State:MI
Mailing Address - Zip Code:49783-1899
Mailing Address - Country:US
Mailing Address - Phone:906-635-2969
Mailing Address - Fax:906-635-3114
Practice Address - Street 1:550 OSBORN BLVD STE 1006
Practice Address - Street 2:
Practice Address - City:SAULT SAINTE MARIE
Practice Address - State:MI
Practice Address - Zip Code:49783-1899
Practice Address - Country:US
Practice Address - Phone:906-635-2969
Practice Address - Fax:906-635-3114
Is Sole Proprietor?:No
Enumeration Date:2012-01-19
Last Update Date:2013-05-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704195098363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health