Provider Demographics
NPI:1023151628
Name:WILSON, THERESA (APRN)
Entity type:Individual
Prefix:
First Name:THERESA
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:231 WILSON PIKE CIR STE 200
Mailing Address - Street 2:
Mailing Address - City:BRENTWOOD
Mailing Address - State:TN
Mailing Address - Zip Code:37027-5286
Mailing Address - Country:US
Mailing Address - Phone:615-628-7176
Mailing Address - Fax:615-454-9201
Practice Address - Street 1:231 WILSON PIKE CIR STE 200
Practice Address - Street 2:
Practice Address - City:BRENTWOOD
Practice Address - State:TN
Practice Address - Zip Code:37027-5286
Practice Address - Country:US
Practice Address - Phone:615-628-7176
Practice Address - Fax:615-454-9201
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-14
Last Update Date:2019-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN132505163WP0809X
TN13106363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163WP0809XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Adult
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1511497Medicaid