Provider Demographics
NPI:1740064823
Name:WILSON, MICHELLE (APN-C)
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:APN-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3803 W CHESTER PIKE STE 160
Mailing Address - Street 2:
Mailing Address - City:NEWTOWN SQUARE
Mailing Address - State:PA
Mailing Address - Zip Code:19073-2336
Mailing Address - Country:US
Mailing Address - Phone:484-337-1632
Mailing Address - Fax:
Practice Address - Street 1:107 TOWN CENTER RD
Practice Address - Street 2:
Practice Address - City:KING OF PRUSSIA
Practice Address - State:PA
Practice Address - Zip Code:19406-2330
Practice Address - Country:US
Practice Address - Phone:484-750-5212
Practice Address - Fax:484-750-5212
Is Sole Proprietor?:No
Enumeration Date:2023-08-21
Last Update Date:2024-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP027848363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner