Provider Demographics
NPI:1285826057
Name:WILSON, KIMBERLY ELLISON (CRNP)
Entity Type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:ELLISON
Last Name:WILSON
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1325 MCFARLAND BLVD
Mailing Address - Street 2:SUITE 104
Mailing Address - City:NORTHPORT
Mailing Address - State:AL
Mailing Address - Zip Code:35476-3270
Mailing Address - Country:US
Mailing Address - Phone:205-330-5266
Mailing Address - Fax:205-330-9915
Practice Address - Street 1:1325 MCFARLAND BLVD
Practice Address - Street 2:SUITE 104
Practice Address - City:NORTHPORT
Practice Address - State:AL
Practice Address - Zip Code:35476-3270
Practice Address - Country:US
Practice Address - Phone:205-330-5266
Practice Address - Fax:205-330-9915
Is Sole Proprietor?:No
Enumeration Date:2007-08-15
Last Update Date:2012-09-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL1-078924363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
AL511-00428OtherBCBS OF ALABAMA
AL115069/1336474964Medicaid
AL102I508386Medicare PIN