Provider Demographics
NPI:1619362076
Name:WILSON, CACIA L
Entity type:Individual
Prefix:
First Name:CACIA
Middle Name:L
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 1:3750 LANDMARK DR STE A
Mailing Address - Street 2:
Mailing Address - City:LAFAYETTE
Mailing Address - State:IN
Mailing Address - Zip Code:47905-6652
Mailing Address - Country:US
Mailing Address - Phone:765-448-4511
Mailing Address - Fax:765-447-7312
Practice Address - Street 1:3750 LANDMARK DR STE A
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:IN
Practice Address - Zip Code:47905-6652
Practice Address - Country:US
Practice Address - Phone:765-448-4511
Practice Address - Fax:765-447-7312
Is Sole Proprietor?:No
Enumeration Date:2015-04-02
Last Update Date:2021-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28195527A163W00000X
IN71005451A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN201287850Medicaid
INP01512454OtherRR MEDICARE
IN266180523Medicare PIN