Provider Demographics
NPI:1952535171
Name:WILSON, NICOLE DENISE (APN)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:DENISE
Last Name:WILSON
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 655
Mailing Address - Street 2:
Mailing Address - City:SAVANNAH
Mailing Address - State:TN
Mailing Address - Zip Code:38372-0655
Mailing Address - Country:US
Mailing Address - Phone:731-925-2300
Mailing Address - Fax:731-925-2157
Practice Address - Street 1:765 FLORENCE RD
Practice Address - Street 2:
Practice Address - City:SAVANNAH
Practice Address - State:TN
Practice Address - Zip Code:38372-3451
Practice Address - Country:US
Practice Address - Phone:731-925-2300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-05-04
Last Update Date:2024-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN14149363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
4235392OtherBCBS
TN1513972Medicaid
3345612Medicare PIN