Provider Demographics
NPI:1811373194
Name:WILSON, ANNISSA ANNETTE (FNP-C)
Entity Type:Individual
Prefix:
First Name:ANNISSA
Middle Name:ANNETTE
Last Name:WILSON
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 529
Mailing Address - Street 2:
Mailing Address - City:ROYSTON
Mailing Address - State:GA
Mailing Address - Zip Code:30662-0529
Mailing Address - Country:US
Mailing Address - Phone:706-363-9229
Mailing Address - Fax:706-621-7557
Practice Address - Street 1:2805 HAMILTON MILL RD
Practice Address - Street 2:
Practice Address - City:BUFORD
Practice Address - State:GA
Practice Address - Zip Code:30519-4110
Practice Address - Country:US
Practice Address - Phone:678-541-0588
Practice Address - Fax:678-541-0610
Is Sole Proprietor?:No
Enumeration Date:2015-08-10
Last Update Date:2016-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN177871363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily