Provider Demographics
NPI:1568139095
Name:WILSON, MISTY LEA
Entity Type:Individual
Prefix:
First Name:MISTY
Middle Name:LEA
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 1:926 E WEBSTER ST
Mailing Address - Street 2:
Mailing Address - City:BENTON
Mailing Address - State:IL
Mailing Address - Zip Code:62812-3234
Mailing Address - Country:US
Mailing Address - Phone:618-316-9956
Mailing Address - Fax:
Practice Address - Street 1:405 S MAIN ST
Practice Address - Street 2:
Practice Address - City:BELLE RIVE
Practice Address - State:IL
Practice Address - Zip Code:62810-1228
Practice Address - Country:US
Practice Address - Phone:618-316-1626
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-24
Last Update Date:2021-08-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider