Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 363LP0808X | Nurse Practitioner - Psychiatric/Mental Health | 13106 | TN |
NPI | 1023151628 |
---|---|
Provider Name | Theresa Wilson |
First Address | Brentwood, TN 37027-5286 |
Second Address | Brentwood, TN 37027-5286 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 14/02/2007 |
Last Update Date | 26/09/2019 |
IDENTIFIER | TYPE / CODE | IDENTIFIER STATE |
---|---|---|
1511497 | (05) | TN |