Provider Demographics
NPI:1023578846
Name:WILT, WESLEY STEPHENS (STUDENT)
Entity Type:Individual
Prefix:
First Name:WESLEY
Middle Name:STEPHENS
Last Name:WILT
Suffix:
Gender:F
Credentials:STUDENT
Other - Prefix:
Other - First Name:WESLEY
Other - Middle Name:ANNE
Other - Last Name:STEPHENS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:800 ROSE ST # C-246
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40536-0293
Mailing Address - Country:US
Mailing Address - Phone:859-323-6162
Mailing Address - Fax:859-257-8934
Practice Address - Street 1:800 ROSE ST # C-246
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40536-7001
Practice Address - Country:US
Practice Address - Phone:859-323-6162
Practice Address - Fax:859-257-8934
Is Sole Proprietor?:Yes
Enumeration Date:2019-03-20
Last Update Date:2019-03-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program