Provider Demographics
NPI:1013408111
Name:WILSON, KATRINA
Entity Type:Individual
Prefix:MRS
First Name:KATRINA
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:PO BOX 490623
Mailing Address - Street 2:
Mailing Address - City:LEESBURG
Mailing Address - State:FL
Mailing Address - Zip Code:34749-0623
Mailing Address - Country:US
Mailing Address - Phone:352-396-5254
Mailing Address - Fax:
Practice Address - Street 1:1416 GRIFFIN RD APT 57
Practice Address - Street 2:
Practice Address - City:LEESBURG
Practice Address - State:FL
Practice Address - Zip Code:34748-3439
Practice Address - Country:US
Practice Address - Phone:352-396-5254
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-23
Last Update Date:2018-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes385H00000XRespite Care FacilityRespite Care