Provider Demographics
NPI:1912029224
Name:WILSON, JANET DIANE (FNP-BC)
Entity Type:Individual
Prefix:
First Name:JANET
Middle Name:DIANE
Last Name:WILSON
Suffix:
Gender:F
Credentials:FNP-BC
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 905
Mailing Address - Street 2:
Mailing Address - City:ST JOHNSBURY
Mailing Address - State:VT
Mailing Address - Zip Code:05819-0905
Mailing Address - Country:US
Mailing Address - Phone:802-748-8141
Mailing Address - Fax:802-748-4098
Practice Address - Street 1:1315 HOSPITAL DRIVE
Practice Address - Street 2:
Practice Address - City:ST JOHNSBURY
Practice Address - State:VT
Practice Address - Zip Code:05819-0905
Practice Address - Country:US
Practice Address - Phone:802-748-8141
Practice Address - Fax:802-748-4098
Is Sole Proprietor?:No
Enumeration Date:2007-04-06
Last Update Date:2009-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN12631363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1511739OtherMEDICAID MCC TEMP#
TN33413733Medicare PIN