Provider Demographics
NPI:1386068690
Name:WILSON, WENDY LADAWN (FNP BC)
Entity type:Individual
Prefix:
First Name:WENDY
Middle Name:LADAWN
Last Name:WILSON
Suffix:
Gender:F
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 1:230 GEORGE ST STE 2
Mailing Address - Street 2:
Mailing Address - City:BECKLEY
Mailing Address - State:WV
Mailing Address - Zip Code:25801-2620
Mailing Address - Country:US
Mailing Address - Phone:304-255-2878
Mailing Address - Fax:304-465-5486
Practice Address - Street 1:230 GEORGE ST STE 2
Practice Address - Street 2:
Practice Address - City:BECKLEY
Practice Address - State:WV
Practice Address - Zip Code:25801-2620
Practice Address - Country:US
Practice Address - Phone:304-255-2878
Practice Address - Fax:304-465-5486
Is Sole Proprietor?:No
Enumeration Date:2014-02-06
Last Update Date:2022-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WV64413363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3810027051Medicaid
WVWV3950AMedicare PIN