Provider Demographics
NPI:1770835332
Name:WILSON, DEANN (PNP-BC)
Entity Type:Individual
Prefix:MRS
First Name:DEANN
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:PNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:621 S NEW BALLAS RD STE 1001B
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63141-8264
Mailing Address - Country:US
Mailing Address - Phone:314-872-8752
Mailing Address - Fax:314-872-3963
Practice Address - Street 1:621 S NEW BALLAS RD STE 1001B
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-8264
Practice Address - Country:US
Practice Address - Phone:314-251-4772
Practice Address - Fax:314-251-5772
Is Sole Proprietor?:No
Enumeration Date:2012-10-08
Last Update Date:2023-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2011037438363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics