Provider Demographics
NPI:1275858599
Name:WILBURN, CATHY (FNP-BC)
Entity Type:Individual
Prefix:
First Name:CATHY
Middle Name:
Last Name:WILBURN
Suffix:
Gender:F
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 187
Mailing Address - Street 2:
Mailing Address - City:HOULKA
Mailing Address - State:MS
Mailing Address - Zip Code:38850-0187
Mailing Address - Country:US
Mailing Address - Phone:662-568-3316
Mailing Address - Fax:662-568-3360
Practice Address - Street 1:301 JACKSON AVE W
Practice Address - Street 2:
Practice Address - City:OXFORD
Practice Address - State:MS
Practice Address - Zip Code:38655-2154
Practice Address - Country:US
Practice Address - Phone:662-234-6464
Practice Address - Fax:662-234-6433
Is Sole Proprietor?:No
Enumeration Date:2010-03-30
Last Update Date:2015-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR850403363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS09521395Medicaid