Provider Demographics
NPI:1639106651
Name:WILSON, NANCY GRACE RUSSO (ARNP)
Entity Type:Individual
Prefix:MRS
First Name:NANCY
Middle Name:GRACE RUSSO
Last Name:WILSON
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:5132 OCEAN BLVD
Mailing Address - Street 2:
Mailing Address - City:SARASOTA
Mailing Address - State:FL
Mailing Address - Zip Code:34242-1637
Mailing Address - Country:US
Mailing Address - Phone:941-349-1411
Mailing Address - Fax:941-346-0885
Practice Address - Street 1:5132 OCEAN BLVD
Practice Address - Street 2:
Practice Address - City:SARASOTA
Practice Address - State:FL
Practice Address - Zip Code:34242-1637
Practice Address - Country:US
Practice Address - Phone:941-349-1411
Practice Address - Fax:941-346-0885
Is Sole Proprietor?:No
Enumeration Date:2006-06-26
Last Update Date:2007-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9228952363LF0000X
NYNYS330384363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLS17830Medicare UPIN