1114537222 NPI number — NATALIE JOAN WILSON CPNP

Table of content: NATALIE JOAN WILSON CPNP (NPI 1114537222)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1114537222 NPI number — NATALIE JOAN WILSON CPNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WILSON
Provider First Name:
NATALIE
Provider Middle Name:
JOAN
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CPNP
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1114537222
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
08/04/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1463 US HIGHWAY 61 STE C
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
FESTUS
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
63028-4160
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
314-596-6541
Provider Business Mailing Address Fax Number:
636-933-2190

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1463 US HWY 61
Provider Second Line Business Practice Location Address:
SUITE C
Provider Business Practice Location Address City Name:
FESTUS
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
63028-6302
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
314-596-6541
Provider Business Practice Location Address Fax Number:
636-933-2910
Provider Enumeration Date:
08/04/2020

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: 208000000X , with the licence number:  2020010590 , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 2013015912 . This is a "RN" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".
  • Identifier: 2020010590 . This is a "PNCB CERTIFICATION NUMBER" identifier , issued by the state of ( MO ) . This identifiers is of the category "OTHER".




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