Provider Demographics
NPI:1972773075
Name:WILSON, BETTY J (FNP)
Entity Type:Individual
Prefix:MRS
First Name:BETTY
Middle Name:J
Last Name:WILSON
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:BETTY
Other - Middle Name:J
Other - Last Name:WOLFENBARGER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 850
Mailing Address - Street 2:
Mailing Address - City:ROGERSVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37857-0850
Mailing Address - Country:US
Mailing Address - Phone:423-272-6969
Mailing Address - Fax:423-921-6920
Practice Address - Street 1:2927 HIGHWAY 66 S
Practice Address - Street 2:
Practice Address - City:ROGERSVILLE
Practice Address - State:TN
Practice Address - Zip Code:37857-5169
Practice Address - Country:US
Practice Address - Phone:423-272-6969
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-03-04
Last Update Date:2009-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNAPN0000005031363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN33416361Medicaid
3703864Medicare PIN
33416361Medicare PIN
S24245Medicare UPIN
TN33416361Medicaid