Provider Demographics
NPI:1245705847
Name:WILSON, SHAYE (FNP-C)
Entity type:Individual
Prefix:
First Name:SHAYE
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10700 S STATE HIGHWAY 43
Mailing Address - Street 2:
Mailing Address - City:SOUTH WEST CITY
Mailing Address - State:MO
Mailing Address - Zip Code:64863-7272
Mailing Address - Country:US
Mailing Address - Phone:417-762-5250
Mailing Address - Fax:
Practice Address - Street 1:10700 S STATE HIGHWAY 43
Practice Address - Street 2:
Practice Address - City:SOUTH WEST CITY
Practice Address - State:MO
Practice Address - Zip Code:64863-7272
Practice Address - Country:US
Practice Address - Phone:417-762-5250
Practice Address - Fax:177-625-2524
Is Sole Proprietor?:No
Enumeration Date:2018-10-10
Last Update Date:2022-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2019012514363L00000X
ARA006255363L00000X
OK112102363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner