Provider Demographics
NPI:1710307889
Name:WILSON, LISA RUTH (AGNP)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:RUTH
Last Name:WILSON
Suffix:
Gender:F
Credentials:AGNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24776 STATE HIGHWAY EE
Mailing Address - Street 2:
Mailing Address - City:WARRENTON
Mailing Address - State:MO
Mailing Address - Zip Code:63383-5883
Mailing Address - Country:US
Mailing Address - Phone:636-795-0342
Mailing Address - Fax:
Practice Address - Street 1:324 W 5TH ST
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:MO
Practice Address - Zip Code:63090-2306
Practice Address - Country:US
Practice Address - Phone:636-795-0342
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-04-16
Last Update Date:2014-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2014010130363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health