Provider Demographics
NPI:1598571093
Name:WILSON, PENNY
Entity type:Individual
Prefix:
First Name:PENNY
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1103 E MAIN ST STE C
Mailing Address - Street 2:
Mailing Address - City:MOUNTAIN VIEW
Mailing Address - State:AR
Mailing Address - Zip Code:72560-4007
Mailing Address - Country:US
Mailing Address - Phone:877-683-2993
Mailing Address - Fax:866-922-9146
Practice Address - Street 1:1103 E MAIN ST STE C
Practice Address - Street 2:
Practice Address - City:MOUNTAIN VIEW
Practice Address - State:AR
Practice Address - Zip Code:72560-4007
Practice Address - Country:US
Practice Address - Phone:877-683-2993
Practice Address - Fax:866-922-9146
Is Sole Proprietor?:No
Enumeration Date:2024-12-09
Last Update Date:2024-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR123612164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse