Provider Demographics
NPI:1043423072
Name:WILSON, KATE (LAC)
Entity Type:Individual
Prefix:
First Name:KATE
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2955 PARK AVENUE
Mailing Address - Street 2:
Mailing Address - City:SOQUEL
Mailing Address - State:CA
Mailing Address - Zip Code:95073
Mailing Address - Country:US
Mailing Address - Phone:831-566-4838
Mailing Address - Fax:831-476-6198
Practice Address - Street 1:2955 PARK AVENUE
Practice Address - Street 2:
Practice Address - City:SOQUEL
Practice Address - State:CA
Practice Address - Zip Code:95073
Practice Address - Country:US
Practice Address - Phone:831-566-4838
Practice Address - Fax:831-476-6198
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-07
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC 8798171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist