Provider Demographics
NPI:1447049739
Name:WILSON, TERENCE F
Entity type:Individual
Prefix:
First Name:TERENCE
Middle Name:F
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 1:9630 S KOMENSKY AVE APT 210
Mailing Address - Street 2:
Mailing Address - City:OAK LAWN
Mailing Address - State:IL
Mailing Address - Zip Code:60453-3360
Mailing Address - Country:US
Mailing Address - Phone:929-372-0380
Mailing Address - Fax:
Practice Address - Street 1:9630 S KOMENSKY AVE APT 210
Practice Address - Street 2:
Practice Address - City:OAK LAWN
Practice Address - State:IL
Practice Address - Zip Code:60453-3360
Practice Address - Country:US
Practice Address - Phone:929-372-0380
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-05-02
Last Update Date:2025-05-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ILAG04250063363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health