Provider Demographics
NPI:1255625216
Name:WILSON, HEATHER LYNNE (APRN)
Entity type:Individual
Prefix:
First Name:HEATHER
Middle Name:LYNNE
Last Name:WILSON
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:HEATHER
Other - Middle Name:LYNNE
Other - Last Name:ROSE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:2110 SILAS DEANE HWY
Mailing Address - Street 2:
Mailing Address - City:ROCKY HILL
Mailing Address - State:CT
Mailing Address - Zip Code:06067-2313
Mailing Address - Country:US
Mailing Address - Phone:860-258-3470
Mailing Address - Fax:860-571-6800
Practice Address - Street 1:85 SEYMOUR ST
Practice Address - Street 2:SUITE 900
Practice Address - City:HARTFORD
Practice Address - State:CT
Practice Address - Zip Code:06106-5501
Practice Address - Country:US
Practice Address - Phone:860-241-0700
Practice Address - Fax:860-525-7881
Is Sole Proprietor?:No
Enumeration Date:2011-06-07
Last Update Date:2015-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT004730363LA2100X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004047304Medicaid
CTD400062224 - C00023Medicare PIN
CTD400062223 - C00814Medicare PIN