1245342344 NPI number — MS. JO LYNN WILSON CRNA

Table of content: MS. JO LYNN WILSON CRNA (NPI 1245342344)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1245342344 NPI number — MS. JO LYNN WILSON CRNA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WILSON
Provider First Name:
JO
Provider Middle Name:
LYNN
Provider Name Prefix Text:
MS.
Provider Name Suffix Text:
Provider Credential Text:
CRNA
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BORN
Provider Other First Name:
JO
Provider Other Middle Name:
LYNN
Provider Other Name Prefix Text:
MS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1245342344
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
03/18/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4916 OVERTON PLZ
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FORT WORTH
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
76109-4415
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
817-529-1920
Provider Business Mailing Address Fax Number:
817-334-0235

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
800 12TH AVE
Provider Second Line Business Practice Location Address:
STE. 100
Provider Business Practice Location Address City Name:
FORT WORTH
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
76104-2518
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
817-810-0600
Provider Business Practice Location Address Fax Number:
817-236-1394
Provider Enumeration Date:
08/31/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 367500000X , with the licence number:  226528 , registered in the state of TX ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 162546901 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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