Provider Demographics
NPI:1376670570
Name:WILSON, KALA WHITE (CFNP)
Entity Type:Individual
Prefix:
First Name:KALA
Middle Name:WHITE
Last Name:WILSON
Suffix:
Gender:F
Credentials:CFNP
Other - Prefix:MRS
Other - First Name:KALA
Other - Middle Name:NICOLE
Other - Last Name:PHILLIPS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:724 LEIGH DR
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS
Mailing Address - State:MS
Mailing Address - Zip Code:39705-3098
Mailing Address - Country:US
Mailing Address - Phone:662-328-3375
Mailing Address - Fax:662-328-3395
Practice Address - Street 1:724 LEIGH DR
Practice Address - Street 2:
Practice Address - City:COLUMBUS
Practice Address - State:MS
Practice Address - Zip Code:39705-3098
Practice Address - Country:US
Practice Address - Phone:662-328-3375
Practice Address - Fax:662-328-3395
Is Sole Proprietor?:No
Enumeration Date:2007-02-27
Last Update Date:2021-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR865872363L00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MSR865872OtherRN NP LICENSE NUMBER
302I509924Medicare UPIN