Provider Demographics
NPI:1770658551
Name:WILSON, MYRENE CHRISTINE (FNP)
Entity Type:Individual
Prefix:
First Name:MYRENE
Middle Name:CHRISTINE
Last Name:WILSON
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1801 E STATE ROUTE K
Mailing Address - Street 2:
Mailing Address - City:WEST PLAINS
Mailing Address - State:MO
Mailing Address - Zip Code:65775-6616
Mailing Address - Country:US
Mailing Address - Phone:417-257-2454
Mailing Address - Fax:417-256-1119
Practice Address - Street 1:1801 E STATE ROUTE K
Practice Address - Street 2:
Practice Address - City:WEST PLAINS
Practice Address - State:MO
Practice Address - Zip Code:65775-6616
Practice Address - Country:US
Practice Address - Phone:417-257-2454
Practice Address - Fax:417-256-1119
Is Sole Proprietor?:No
Enumeration Date:2006-11-21
Last Update Date:2014-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA01747363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily