Provider Demographics
NPI:1770048084
Name:WILSON, CASEY RENEE (APRN)
Entity type:Individual
Prefix:MRS
First Name:CASEY
Middle Name:RENEE
Last Name:WILSON
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:209 THOMPSON AVE # 2
Mailing Address - Street 2:
Mailing Address - City:EL DORADO
Mailing Address - State:AR
Mailing Address - Zip Code:71730-5755
Mailing Address - Country:US
Mailing Address - Phone:870-864-0333
Mailing Address - Fax:
Practice Address - Street 1:209 THOMPSON AVE # 2
Practice Address - Street 2:
Practice Address - City:EL DORADO
Practice Address - State:AR
Practice Address - Zip Code:71730-5755
Practice Address - Country:US
Practice Address - Phone:870-864-0333
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-31
Last Update Date:2019-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ARA006064363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily