Provider Demographics
NPI:1700567591
Name:WILSON, NICOLE (FNP-C)
Entity Type:Individual
Prefix:
First Name:NICOLE
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 1:2848 MORIN POINT ST
Mailing Address - Street 2:
Mailing Address - City:ERIE
Mailing Address - State:MI
Mailing Address - Zip Code:48133-9616
Mailing Address - Country:US
Mailing Address - Phone:734-652-7165
Mailing Address - Fax:
Practice Address - Street 1:950 W WOOSTER ST
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:OH
Practice Address - Zip Code:43402-2603
Practice Address - Country:US
Practice Address - Phone:419-354-8900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-07-26
Last Update Date:2023-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIAPRN.CNP.0034508363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner