Provider Demographics
NPI:1558070995
Name:WILSON, JOANNA LEE (PNP)
Entity type:Individual
Prefix:
First Name:JOANNA
Middle Name:LEE
Last Name:WILSON
Suffix:
Gender:F
Credentials:PNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3966 W 38TH ST
Mailing Address - Street 2:
Mailing Address - City:CASPER
Mailing Address - State:WY
Mailing Address - Zip Code:82604-4293
Mailing Address - Country:US
Mailing Address - Phone:307-267-6642
Mailing Address - Fax:
Practice Address - Street 1:3966 W 38TH ST
Practice Address - Street 2:
Practice Address - City:CASPER
Practice Address - State:WY
Practice Address - Zip Code:82604-4293
Practice Address - Country:US
Practice Address - Phone:307-267-6642
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-15
Last Update Date:2022-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WY36659163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163W00000XNursing Service ProvidersRegistered NurseGroup - Single Specialty