Provider Demographics
NPI:1326387556
Name:WILKERSON, KRISTIN JEAN (NP)
Entity Type:Individual
Prefix:
First Name:KRISTIN
Middle Name:JEAN
Last Name:WILKERSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 S WELLS RD
Mailing Address - Street 2:#200
Mailing Address - City:VENTURA
Mailing Address - State:CA
Mailing Address - Zip Code:93004-1377
Mailing Address - Country:US
Mailing Address - Phone:805-659-1740
Mailing Address - Fax:805-659-9959
Practice Address - Street 1:1722 S LEWIS RD
Practice Address - Street 2:
Practice Address - City:CAMARILLO
Practice Address - State:CA
Practice Address - Zip Code:93012-8520
Practice Address - Country:US
Practice Address - Phone:805-445-7800
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-02-07
Last Update Date:2019-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR876185163W00000X
CA95000211363LF0000X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily