Provider Demographics
NPI:1275034480
Name:WILSON, DANIELLE LYNN
Entity type:Individual
Prefix:
First Name:DANIELLE
Middle Name:LYNN
Last Name:WILSON
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:145 LAKE SPRING CIR
Mailing Address - Street 2:
Mailing Address - City:GEORGETOWN
Mailing Address - State:TX
Mailing Address - Zip Code:78633-2186
Mailing Address - Country:US
Mailing Address - Phone:512-799-9284
Mailing Address - Fax:
Practice Address - Street 1:1266 E MAIN ST STE 700R
Practice Address - Street 2:
Practice Address - City:STAMFORD
Practice Address - State:CT
Practice Address - Zip Code:06902-3507
Practice Address - Country:US
Practice Address - Phone:877-723-2007
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-22
Last Update Date:2025-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTAP7483163WP0808X
TXAP136628363LF0000X
CT7483363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily