Provider Demographics
NPI:1629782107
Name:WILSON, TAYLER (CRNA)
Entity Type:Individual
Prefix:
First Name:TAYLER
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1512 EFFIE HWY
Mailing Address - Street 2:
Mailing Address - City:DEVILLE
Mailing Address - State:LA
Mailing Address - Zip Code:71328-2600
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:651 N BOLTON AVE
Practice Address - Street 2:
Practice Address - City:ALEXANDRIA
Practice Address - State:LA
Practice Address - Zip Code:71301-7449
Practice Address - Country:US
Practice Address - Phone:318-443-3511
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-10
Last Update Date:2023-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA229067367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered