Provider Demographics
NPI:1013971431
Name:WILSON, HEATHER LYNN (MD)
Entity Type:Individual
Prefix:DR
First Name:HEATHER
Middle Name:LYNN
Last Name:WILSON
Suffix:
Gender:F
Credentials:MD
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 776351
Mailing Address - Street 2:
Mailing Address - City:CHICAGO
Mailing Address - State:IL
Mailing Address - Zip Code:60677-6351
Mailing Address - Country:US
Mailing Address - Phone:502-588-9490
Mailing Address - Fax:502-272-5116
Practice Address - Street 1:4123 DUTCHMANS LN STE 500
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40207-4730
Practice Address - Country:US
Practice Address - Phone:502-894-9494
Practice Address - Fax:502-894-9404
Is Sole Proprietor?:No
Enumeration Date:2006-04-13
Last Update Date:2019-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY38951207VX0000X, 207VX0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207VX0000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyObstetrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY6408377Medicaid
KYP00983047OtherMEDICARE RR
I03704Medicare UPIN
KY6408377Medicaid
KYK005740Medicare Oscar/Certification