Provider Demographics
NPI:1710604780
Name:WILSON, LAURA ANN (FNP-C)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:ANN
Last Name:WILSON
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:LAURA
Other - Middle Name:ANN
Other - Last Name:WHELAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1130 JACOB DR
Mailing Address - Street 2:
Mailing Address - City:RED BUD
Mailing Address - State:IL
Mailing Address - Zip Code:62278-2433
Mailing Address - Country:US
Mailing Address - Phone:618-719-4939
Mailing Address - Fax:
Practice Address - Street 1:1000 ELEVEN S STE 1A
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:IL
Practice Address - Zip Code:62236-1078
Practice Address - Country:US
Practice Address - Phone:618-281-8400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-20
Last Update Date:2022-10-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209026113363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily