Provider Demographics
NPI:1578767281
Name:WILSON, HEATHER L
Entity Type:Individual
Prefix:MRS
First Name:HEATHER
Middle Name:L
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 1:203 SOUTH ST
Mailing Address - Street 2:
Mailing Address - City:LENA
Mailing Address - State:IL
Mailing Address - Zip Code:61048-9203
Mailing Address - Country:US
Mailing Address - Phone:309-371-7675
Mailing Address - Fax:
Practice Address - Street 1:701 W LAMM RD
Practice Address - Street 2:
Practice Address - City:FREEPORT
Practice Address - State:IL
Practice Address - Zip Code:61032-9630
Practice Address - Country:US
Practice Address - Phone:815-233-6162
Practice Address - Fax:815-233-6167
Is Sole Proprietor?:No
Enumeration Date:2007-06-14
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator