Provider Demographics
NPI: | 1619362076 |
---|---|
Name: | WILSON, CACIA L |
Entity Type: | Individual |
Prefix: | |
First Name: | CACIA |
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: | 3750 LANDMARK DR STE A |
Mailing Address - Street 2: | |
Mailing Address - City: | LAFAYETTE |
Mailing Address - State: | IN |
Mailing Address - Zip Code: | 47905-6652 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 765-448-4511 |
Mailing Address - Fax: | 765-447-7312 |
Practice Address - Street 1: | 3750 LANDMARK DR STE A |
Practice Address - Street 2: | |
Practice Address - City: | LAFAYETTE |
Practice Address - State: | IN |
Practice Address - Zip Code: | 47905-6652 |
Practice Address - Country: | US |
Practice Address - Phone: | 765-448-4511 |
Practice Address - Fax: | 765-447-7312 |
Is Sole Proprietor?: | No |
Enumeration Date: | 2015-04-02 |
Last Update Date: | 2021-03-29 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Licenses
State | License ID | Taxonomies |
---|---|---|
IN | 28195527A | 163W00000X |
IN | 71005451A | 363LF0000X |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 363LF0000X | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No | 163W00000X | Nursing Service Providers | Registered Nurse |
Provider Identifiers
State | Identifier ID | ID Type | Issuer |
---|---|---|---|
IN | 201287850 | Medicaid | |
IN | P01512454 | Other | RR MEDICARE |
IN | 266180523 | Medicare PIN |