Provider Demographics
NPI:1982000568
Name:WILSON, STACY A (FNP)
Entity Type:Individual
Prefix:
First Name:STACY
Middle Name:A
Last Name:WILSON
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:STACY
Other - Middle Name:A
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP-C
Mailing Address - Street 1:1160 E SAINT CLAIR ST
Mailing Address - Street 2:
Mailing Address - City:VINCENNES
Mailing Address - State:IN
Mailing Address - Zip Code:47591-4853
Mailing Address - Country:US
Mailing Address - Phone:812-885-3325
Mailing Address - Fax:812-885-8987
Practice Address - Street 1:328 N 2ND ST STE 307
Practice Address - Street 2:
Practice Address - City:VINCENNES
Practice Address - State:IN
Practice Address - Zip Code:47591-1353
Practice Address - Country:US
Practice Address - Phone:812-882-2703
Practice Address - Fax:812-882-2760
Is Sole Proprietor?:No
Enumeration Date:2014-11-10
Last Update Date:2024-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71005227A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily