1083047369 NPI number — BRIANNA JEAN WILSON DNP, ARNP

Table of content: BRIANNA JEAN WILSON DNP, ARNP (NPI 1083047369)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1083047369 NPI number — BRIANNA JEAN WILSON DNP, ARNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WILSON
Provider First Name:
BRIANNA
Provider Middle Name:
JEAN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
DNP, ARNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
BOWE
Provider Other First Name:
BRIANNA
Provider Other Middle Name:
JEAN
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
RN
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1083047369
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
01/15/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 2104
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LA CONNER
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98257-2104
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
360-630-5141
Provider Business Mailing Address Fax Number:
866-302-7491

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
708 E MORRIS ST
Provider Second Line Business Practice Location Address:
STE B
Provider Business Practice Location Address City Name:
LA CONNER
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98257-9825
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
360-630-5141
Provider Business Practice Location Address Fax Number:
877-850-2373
Provider Enumeration Date:
08/09/2013

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: 363LF0000X , with the licence number:  AP60404988 , registered in the state of WA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 1083047369 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




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