Provider Demographics
NPI:1003258567
Name:WILKERSON, DEBRA (LPN)
Entity Type:Individual
Prefix:
First Name:DEBRA
Middle Name:
Last Name:WILKERSON
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:176 EDWARD ST
Mailing Address - Street 2:
Mailing Address - City:MARISSA
Mailing Address - State:IL
Mailing Address - Zip Code:62257-3552
Mailing Address - Country:US
Mailing Address - Phone:618-975-5295
Mailing Address - Fax:618-939-4181
Practice Address - Street 1:988 N ILLINOIS ROUTE 3
Practice Address - Street 2:
Practice Address - City:WATERLOO
Practice Address - State:IL
Practice Address - Zip Code:62298-1000
Practice Address - Country:US
Practice Address - Phone:618-939-4444
Practice Address - Fax:618-939-4181
Is Sole Proprietor?:Yes
Enumeration Date:2013-07-25
Last Update Date:2013-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL043.114994164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse