Provider Demographics
NPI:1386303329
Name:WILSON, ABIGAIL DIANE (APRN)
Entity type:Individual
Prefix:MRS
First Name:ABIGAIL
Middle Name:DIANE
Last Name:WILSON
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:MISS
Other - First Name:ABIGAIL
Other - Middle Name:DIANE
Other - Last Name:MANGOLD
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:110 W HILLSIDE AVE
Mailing Address - Street 2:
Mailing Address - City:BARRINGTON
Mailing Address - State:IL
Mailing Address - Zip Code:60010-4424
Mailing Address - Country:US
Mailing Address - Phone:847-715-6013
Mailing Address - Fax:
Practice Address - Street 1:5911 NORTHWEST HWY STE 207
Practice Address - Street 2:
Practice Address - City:CRYSTAL LAKE
Practice Address - State:IL
Practice Address - Zip Code:60014-8043
Practice Address - Country:US
Practice Address - Phone:815-526-3781
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-16
Last Update Date:2021-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209024540363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health