Provider Demographics
NPI:1689014672
Name:WILSON, BRANDI MICHELLE (NP)
Entity Type:Individual
Prefix:
First Name:BRANDI
Middle Name:MICHELLE
Last Name:WILSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1422 OLD WEISGARBER RD
Mailing Address - Street 2:
Mailing Address - City:KNOXVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37909-1293
Mailing Address - Country:US
Mailing Address - Phone:865-558-4400
Mailing Address - Fax:
Practice Address - Street 1:1422 OLD WEISGARBER RD
Practice Address - Street 2:
Practice Address - City:KNOXVILLE
Practice Address - State:TN
Practice Address - Zip Code:37909-1293
Practice Address - Country:US
Practice Address - Phone:865-558-4400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-05
Last Update Date:2017-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN17705363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN4356680OtherBLUECROSS BLUESHIELD
TNQ000866Medicaid
TNP01427331OtherRR MEDICARE
TNP01427331OtherRR MEDICARE
TN103I505139Medicare PIN