Provider Demographics
NPI:1740455617
Name:WILSON, JENNIFER LYNN (CRNP)
Entity type:Individual
Prefix:
First Name:JENNIFER
Middle Name:LYNN
Last Name:WILSON
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:JENNIFER
Other - Middle Name:LYNN
Other - Last Name:TATE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNP
Mailing Address - Street 1:199 LAKE BEND DR
Mailing Address - Street 2:
Mailing Address - City:ELMORE
Mailing Address - State:AL
Mailing Address - Zip Code:36025-1058
Mailing Address - Country:US
Mailing Address - Phone:334-714-3868
Mailing Address - Fax:
Practice Address - Street 1:199 LAKE BEND DR
Practice Address - Street 2:
Practice Address - City:ELMORE
Practice Address - State:AL
Practice Address - Zip Code:36025-1058
Practice Address - Country:US
Practice Address - Phone:334-714-3868
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-04-23
Last Update Date:2011-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-082885363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily