Provider Demographics
NPI:1639874662
Name:WILSON, AUTUMN NICOLE (APRN)
Entity Type:Individual
Prefix:
First Name:AUTUMN
Middle Name:NICOLE
Last Name:WILSON
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:105 WALL STREET
Mailing Address - Street 2:
Mailing Address - City:POTEAU
Mailing Address - State:OK
Mailing Address - Zip Code:74953
Mailing Address - Country:US
Mailing Address - Phone:918-635-3576
Mailing Address - Fax:918-635-3332
Practice Address - Street 1:105 WALL STREET
Practice Address - Street 2:
Practice Address - City:POTEAU
Practice Address - State:OK
Practice Address - Zip Code:74953
Practice Address - Country:US
Practice Address - Phone:918-635-3576
Practice Address - Fax:918-635-3332
Is Sole Proprietor?:No
Enumeration Date:2023-03-31
Last Update Date:2024-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OK209703363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily