Provider Demographics
NPI:1669510400
Name:WISDOM, LUCY NELSON (MD)
Entity Type:Individual
Prefix:MRS
First Name:LUCY
Middle Name:NELSON
Last Name:WISDOM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:MISS
Other - First Name:LUCY
Other - Middle Name:A
Other - Last Name:NELSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1404 EASTLAND DRIVE
Mailing Address - Street 2:SUITE 204
Mailing Address - City:BLOOMINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:61701
Mailing Address - Country:US
Mailing Address - Phone:309-662-8813
Mailing Address - Fax:309-662-6835
Practice Address - Street 1:1404 EASTLAND DRIVE
Practice Address - Street 2:SUITE 204
Practice Address - City:BLOOMINGTON
Practice Address - State:IL
Practice Address - Zip Code:61701
Practice Address - Country:US
Practice Address - Phone:309-662-8813
Practice Address - Fax:309-662-6835
Is Sole Proprietor?:No
Enumeration Date:2007-02-02
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL036110740207N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL036110740Medicaid
K06587Medicare ID - Type Unspecified
I06273Medicare UPIN