Provider Demographics
NPI:1639397797
Name:WILSON, MYLA MARIE (RN)
Entity Type:Individual
Prefix:
First Name:MYLA
Middle Name:MARIE
Last Name:WILSON
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2400 S 48TH ST
Mailing Address - Street 2:
Mailing Address - City:SPRINGDALE
Mailing Address - State:AR
Mailing Address - Zip Code:72762-6683
Mailing Address - Country:US
Mailing Address - Phone:479-725-5115
Mailing Address - Fax:479-750-4843
Practice Address - Street 1:2707 BROWNS LN
Practice Address - Street 2:
Practice Address - City:JONESBORO
Practice Address - State:AR
Practice Address - Zip Code:72401-7213
Practice Address - Country:US
Practice Address - Phone:870-972-4050
Practice Address - Fax:479-750-4843
Is Sole Proprietor?:No
Enumeration Date:2007-04-23
Last Update Date:2020-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARR069093163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR173783795Medicaid