Provider Demographics
NPI:1003683996
Name:WILSON, KASEY L (LDO)
Entity Type:Individual
Prefix:MRS
First Name:KASEY
Middle Name:L
Last Name:WILSON
Suffix:
Gender:F
Credentials:LDO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 MARYVILLE HWY STE 204
Mailing Address - Street 2:
Mailing Address - City:SEYMOUR
Mailing Address - State:TN
Mailing Address - Zip Code:37865-5747
Mailing Address - Country:US
Mailing Address - Phone:865-591-9367
Mailing Address - Fax:
Practice Address - Street 1:500 MARYVILLE HWY STE 204
Practice Address - Street 2:
Practice Address - City:SEYMOUR
Practice Address - State:TN
Practice Address - Zip Code:37865-5747
Practice Address - Country:US
Practice Address - Phone:865-591-9367
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-12-11
Last Update Date:2023-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN2199156FX1800X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes156FX1800XEye and Vision Services ProvidersTechnician/TechnologistOptician