Provider Demographics
NPI:1124459730
Name:WILSON, JAVDA MIASHA (NP)
Entity type:Individual
Prefix:MS
First Name:JAVDA
Middle Name:MIASHA
Last Name:WILSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1225 GRAHAM RD
Mailing Address - Street 2:
Mailing Address - City:FLORISSANT
Mailing Address - State:MO
Mailing Address - Zip Code:63031-8012
Mailing Address - Country:US
Mailing Address - Phone:314-963-6994
Mailing Address - Fax:
Practice Address - Street 1:1225 GRAHAM RD
Practice Address - Street 2:
Practice Address - City:FLORISSANT
Practice Address - State:MO
Practice Address - Zip Code:63031-8012
Practice Address - Country:US
Practice Address - Phone:314-963-6994
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-12-06
Last Update Date:2016-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2013043631363LA2200X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health