Provider Demographics
NPI:1376792192
Name:WILSON, KRISTIN (NP)
Entity Type:Individual
Prefix:
First Name:KRISTIN
Middle Name:
Last Name:WILSON
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 1:311 S 3RD ST
Mailing Address - Street 2:
Mailing Address - City:UNION CITY
Mailing Address - State:TN
Mailing Address - Zip Code:38261-3723
Mailing Address - Country:US
Mailing Address - Phone:731-507-0062
Mailing Address - Fax:
Practice Address - Street 1:8132 CORDOVA RD
Practice Address - Street 2:
Practice Address - City:CORDOVA
Practice Address - State:TN
Practice Address - Zip Code:38016
Practice Address - Country:US
Practice Address - Phone:901-405-6470
Practice Address - Fax:901-747-2338
Is Sole Proprietor?:No
Enumeration Date:2008-09-17
Last Update Date:2019-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSA810389363L00000X
TN13402363LF0000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1513081Medicaid
MS30250I8826Medicare PIN