Provider Demographics
NPI:1083829873
Name:WILKES, RUTHANNE
Entity Type:Individual
Prefix:
First Name:RUTHANNE
Middle Name:
Last Name:WILKES
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:RUTHANNE
Other - Middle Name:
Other - Last Name:WILKES
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:CRNP
Mailing Address - Street 1:301 ANDREWS AVENUE
Mailing Address - Street 2:
Mailing Address - City:FORT RUCKER
Mailing Address - State:AL
Mailing Address - Zip Code:36362-7363
Mailing Address - Country:US
Mailing Address - Phone:334-255-7363
Mailing Address - Fax:
Practice Address - Street 1:256 HONEYSUCKLE RD
Practice Address - Street 2:STE 2
Practice Address - City:DOTHAN
Practice Address - State:AL
Practice Address - Zip Code:36305-1168
Practice Address - Country:US
Practice Address - Phone:334-792-6736
Practice Address - Fax:334-792-6737
Is Sole Proprietor?:No
Enumeration Date:2007-05-14
Last Update Date:2018-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-074982363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL891012990Medicaid