Provider Demographics
NPI:1598721417
Name:WILSON, CAROL MITCHELL (RN)
Entity Type:Individual
Prefix:
First Name:CAROL
Middle Name:MITCHELL
Last Name:WILSON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1001 MASONVILLE RD
Mailing Address - Street 2:
Mailing Address - City:MC GEHEE
Mailing Address - State:AR
Mailing Address - Zip Code:71654-9795
Mailing Address - Country:US
Mailing Address - Phone:870-222-3805
Mailing Address - Fax:
Practice Address - Street 1:745 OLD WARREN RD
Practice Address - Street 2:
Practice Address - City:MONTICELLO
Practice Address - State:AR
Practice Address - Zip Code:71655-9713
Practice Address - Country:US
Practice Address - Phone:870-460-7445
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-04-21
Last Update Date:2022-08-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARR69925163WH0200X, 163WP0808X
ARR069925163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No163WH0200XNursing Service ProvidersRegistered NurseHome Health
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health