Provider Demographics
NPI:1619341260
Name:WILSON, CONNIE MARIE (FNP)
Entity Type:Individual
Prefix:
First Name:CONNIE
Middle Name:MARIE
Last Name:WILSON
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1593 E POLSTON AVE
Mailing Address - Street 2:
Mailing Address - City:POST FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83854-5326
Mailing Address - Country:US
Mailing Address - Phone:208-262-2498
Mailing Address - Fax:208-262-7461
Practice Address - Street 1:7173 E SUPER 1 LOOP STE B
Practice Address - Street 2:
Practice Address - City:ATHOL
Practice Address - State:ID
Practice Address - Zip Code:83801-7109
Practice Address - Country:US
Practice Address - Phone:208-561-9901
Practice Address - Fax:208-561-9968
Is Sole Proprietor?:No
Enumeration Date:2015-11-19
Last Update Date:2023-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IDNP-1655A363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
ID1619341260Medicaid