Provider Demographics
NPI:1053393512
Name:WILSON, CAROLINE KREISL (APN)
Entity type:Individual
Prefix:MS
First Name:CAROLINE
Middle Name:KREISL
Last Name:WILSON
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 308
Mailing Address - Street 2:
Mailing Address - City:MISHAWAKA
Mailing Address - State:IN
Mailing Address - Zip Code:46546-0308
Mailing Address - Country:US
Mailing Address - Phone:574-273-6546
Mailing Address - Fax:574-273-5295
Practice Address - Street 1:16450 S 97TH AVE
Practice Address - Street 2:
Practice Address - City:ORLAND PARK
Practice Address - State:IL
Practice Address - Zip Code:60467-5587
Practice Address - Country:US
Practice Address - Phone:708-403-6500
Practice Address - Fax:708-873-9774
Is Sole Proprietor?:Not Answered
Enumeration Date:2005-11-18
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILP77325Medicare UPIN
IL211435Medicare ID - Type Unspecified