Provider Demographics
NPI:1629074539
Name:WILSON, SHALA S (ARNP)
Entity Type:Individual
Prefix:
First Name:SHALA
Middle Name:S
Last Name:WILSON
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:809 MOORELAND DR
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42103-1596
Mailing Address - Country:US
Mailing Address - Phone:270-782-6554
Mailing Address - Fax:
Practice Address - Street 1:1110 WILKINSON TRCE
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42103-3402
Practice Address - Country:US
Practice Address - Phone:270-796-3590
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-06-24
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY2263P363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care