Provider Demographics
NPI:1174508915
Name:WILSON, KATHY A (ARNP)
Entity Type:Individual
Prefix:
First Name:KATHY
Middle Name:A
Last Name:WILSON
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:KATHY
Other - Middle Name:
Other - Last Name:TRIGG
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:ARNP
Mailing Address - Street 1:151 MARY ESTHER BLVD
Mailing Address - Street 2:STE 408
Mailing Address - City:MARY ESTHER
Mailing Address - State:FL
Mailing Address - Zip Code:32569-1975
Mailing Address - Country:US
Mailing Address - Phone:850-863-3000
Mailing Address - Fax:850-862-1621
Practice Address - Street 1:2010 LEWIS TURNER BLVD
Practice Address - Street 2:
Practice Address - City:FORT WALTON BEACH
Practice Address - State:FL
Practice Address - Zip Code:32547-1352
Practice Address - Country:US
Practice Address - Phone:850-863-3000
Practice Address - Fax:850-862-1621
Is Sole Proprietor?:Yes
Enumeration Date:2005-12-14
Last Update Date:2017-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP9162558363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL303882300Medicaid
FLY0302YMedicare PIN
FL303882300Medicaid