Provider Demographics
NPI:1750325833
Name:WILSON, TERESA K (CRNA)
Entity Type:Individual
Prefix:
First Name:TERESA
Middle Name:K
Last Name:WILSON
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3354 CHANTARENE DR
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32507-3549
Mailing Address - Country:US
Mailing Address - Phone:850-455-0954
Mailing Address - Fax:850-455-0954
Practice Address - Street 1:3354 CHANTARENE DR
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32507-3549
Practice Address - Country:US
Practice Address - Phone:850-455-0954
Practice Address - Fax:850-455-0954
Is Sole Proprietor?:No
Enumeration Date:2006-06-16
Last Update Date:2010-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP2989882367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL009982105Medicaid
FL305132300Medicaid
AL59170238OtherBCBS
AL59170239OtherBCBS
P00134519OtherPALMETTO GBA-RR MEDICARE
FLG3172OtherBCBS
AL59170238OtherBCBS