Provider Demographics
NPI:1023881943
Name:WILSON, BRITTANY
Entity type:Individual
Prefix:
First Name:BRITTANY
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:19580 LYLE LN
Mailing Address - Street 2:
Mailing Address - City:WAYNESVILLE
Mailing Address - State:MO
Mailing Address - Zip Code:65583-3571
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:608 OLD ROUTE 66 # MO
Practice Address - Street 2:
Practice Address - City:SAINT ROBERT
Practice Address - State:MO
Practice Address - Zip Code:65584-3730
Practice Address - Country:US
Practice Address - Phone:573-336-8990
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-02
Last Update Date:2023-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2023044267363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily