Provider Demographics
NPI:1154973220
Name:WILSON, NICOLE (OD)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 COSTCO WAY
Mailing Address - Street 2:
Mailing Address - City:SAINT PETERS
Mailing Address - State:MO
Mailing Address - Zip Code:63376-4385
Mailing Address - Country:US
Mailing Address - Phone:636-970-4007
Mailing Address - Fax:314-269-0325
Practice Address - Street 1:200 COSTCO WAY
Practice Address - Street 2:
Practice Address - City:SAINT PETERS
Practice Address - State:MO
Practice Address - Zip Code:63376-4385
Practice Address - Country:US
Practice Address - Phone:636-970-4007
Practice Address - Fax:314-269-0325
Is Sole Proprietor?:No
Enumeration Date:2019-07-09
Last Update Date:2022-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL046.011340L152W00000X
MO2019019708152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist