Provider Demographics
NPI:1033177159
Name:WILSON, KRISTIN NOELLE (OTR/L)
Entity Type:Individual
Prefix:MRS
First Name:KRISTIN
Middle Name:NOELLE
Last Name:WILSON
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3525 HAMM LN
Mailing Address - Street 2:
Mailing Address - City:SPRINGDALE
Mailing Address - State:AR
Mailing Address - Zip Code:72762-0765
Mailing Address - Country:US
Mailing Address - Phone:479-756-0051
Mailing Address - Fax:
Practice Address - Street 1:1760 N WOODLAND AVE
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:AR
Practice Address - Zip Code:72703-2549
Practice Address - Country:US
Practice Address - Phone:479-443-4420
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-01
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AROTR 1316174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AROTR 1316OtherSTATE LICENSE #
AR5U124OtherARBCBS
NBCOT 1024062OtherNAATIONAL O.T. PROVIDER #