Provider Demographics
NPI:1982473997
Name:WILSON THOMAS, NIDRA (PMHNP)
Entity Type:Individual
Prefix:
First Name:NIDRA
Middle Name:
Last Name:WILSON THOMAS
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:MRS
Other - First Name:NIDRA
Other - Middle Name:
Other - Last Name:WILSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1406 BITTERNE CT
Mailing Address - Street 2:
Mailing Address - City:OPELIKA
Mailing Address - State:AL
Mailing Address - Zip Code:36804-3409
Mailing Address - Country:US
Mailing Address - Phone:256-604-6522
Mailing Address - Fax:
Practice Address - Street 1:385 E LAFAYETTE ST
Practice Address - Street 2:
Practice Address - City:DADEVILLE
Practice Address - State:AL
Practice Address - Zip Code:36853-1415
Practice Address - Country:US
Practice Address - Phone:256-825-9244
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-02
Last Update Date:2024-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL2023006483363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health