Provider Demographics
NPI:1013062009
Name:WILSON, MARLENE MARY (FNP)
Entity Type:Individual
Prefix:
First Name:MARLENE
Middle Name:MARY
Last Name:WILSON
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:MARLENE
Other - Middle Name:MARY
Other - Last Name:EDDY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:FNP
Mailing Address - Street 1:PO BOX 100
Mailing Address - Street 2:
Mailing Address - City:BEECH GROVE
Mailing Address - State:IN
Mailing Address - Zip Code:46107-0100
Mailing Address - Country:US
Mailing Address - Phone:317-859-1090
Mailing Address - Fax:317-941-7254
Practice Address - Street 1:6745 GRAY RD STE D
Practice Address - Street 2:
Practice Address - City:INDIANAPOLIS
Practice Address - State:IN
Practice Address - Zip Code:46237-3236
Practice Address - Country:US
Practice Address - Phone:317-859-1090
Practice Address - Fax:317-941-7254
Is Sole Proprietor?:No
Enumeration Date:2007-01-23
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71000629A363L00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN000000545372OtherANTHEM
IN28086560AOtherRN LICENSE
IN000000033846OtherM PLAN
INP00303828OtherRAILROAD MEDICARE
IN11533126OtherCAQH
IN71000629BOtherCSR
IN200509870Medicaid
IN200509870Medicaid
IN71000629BOtherCSR
IN71000629BOtherCSR
IN200509870Medicaid