Provider Demographics
NPI:1336953108
Name:WILSON, ANGELA (FNP-BC)
Entity type:Individual
Prefix:
First Name:ANGELA
Middle Name:
Last Name:WILSON
Suffix:
Gender:
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:367 N 1ST AVE
Mailing Address - Street 2:
Mailing Address - City:CANTON
Mailing Address - State:IL
Mailing Address - Zip Code:61520-1809
Mailing Address - Country:US
Mailing Address - Phone:309-472-6331
Mailing Address - Fax:
Practice Address - Street 1:210 W WALNUT ST
Practice Address - Street 2:
Practice Address - City:CANTON
Practice Address - State:IL
Practice Address - Zip Code:61520-2444
Practice Address - Country:US
Practice Address - Phone:309-647-5240
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-02-03
Last Update Date:2025-03-17
Deactivation Date:2025-03-11
Deactivation Code:
Reactivation Date:2025-03-17
Provider Licenses
StateLicense IDTaxonomies
IL209031848363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily