Provider Demographics
NPI:1457104564
Name:WILSON, RAQUEL (PMHNP-BC)
Entity Type:Individual
Prefix:
First Name:RAQUEL
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1500 OAKLAWN DR
Mailing Address - Street 2:
Mailing Address - City:WEST MEMPHIS
Mailing Address - State:AR
Mailing Address - Zip Code:72301-2996
Mailing Address - Country:US
Mailing Address - Phone:870-740-1174
Mailing Address - Fax:
Practice Address - Street 1:410 S AVALON ST
Practice Address - Street 2:
Practice Address - City:WEST MEMPHIS
Practice Address - State:AR
Practice Address - Zip Code:72301-4183
Practice Address - Country:US
Practice Address - Phone:870-359-2405
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-04-09
Last Update Date:2024-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX927570163W00000X
AR228158363LP0808X
ARR08131163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse