Provider Demographics
NPI:1386282358
Name:WILSON, LISA MAY (MSN, RN, AGACNP-BC)
Entity type:Individual
Prefix:
First Name:LISA
Middle Name:MAY
Last Name:WILSON
Suffix:
Gender:F
Credentials:MSN, RN, AGACNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2488 COLONY WAY
Mailing Address - Street 2:
Mailing Address - City:YPSILANTI
Mailing Address - State:MI
Mailing Address - Zip Code:48197-7446
Mailing Address - Country:US
Mailing Address - Phone:231-445-2691
Mailing Address - Fax:
Practice Address - Street 1:563 LANDINGS BLVD
Practice Address - Street 2:
Practice Address - City:ANN ARBOR
Practice Address - State:MI
Practice Address - Zip Code:48103-2715
Practice Address - Country:US
Practice Address - Phone:231-445-2691
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-12-20
Last Update Date:2021-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704313432163W00000X, 363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No163W00000XNursing Service ProvidersRegistered Nurse