Provider Demographics
NPI:1417984758
Name:WILBURN, DENISE BLAIR
Entity Type:Individual
Prefix:MRS
First Name:DENISE
Middle Name:BLAIR
Last Name:WILBURN
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:DENISE
Other - Middle Name:LAMB, BLAIR
Other - Last Name:WILBURN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:APRN
Mailing Address - Street 1:2100 MARKET ST STE 101
Mailing Address - Street 2:
Mailing Address - City:CHARLESTOWN
Mailing Address - State:IN
Mailing Address - Zip Code:47111-9535
Mailing Address - Country:US
Mailing Address - Phone:812-503-5100
Mailing Address - Fax:770-573-9513
Practice Address - Street 1:1802 E 10TH ST
Practice Address - Street 2:
Practice Address - City:JEFFERSONVILLE
Practice Address - State:IN
Practice Address - Zip Code:47130-6016
Practice Address - Country:US
Practice Address - Phone:812-288-2488
Practice Address - Fax:770-573-9513
Is Sole Proprietor?:No
Enumeration Date:2006-06-26
Last Update Date:2021-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY3004516363LF0000X
KY4516P363LF0000X
IN71001728A207QA0401X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No207QA0401XAllopathic & Osteopathic PhysiciansFamily MedicineAddiction Medicine
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN71001728AOtherLICENSE NUMBER
KY4526POtherARNP LICENSE
KY3004516OtherLICENSE NUMBER
KYK156040OtherMEDICARE PTAN
KY1105450OtherRN LICENSE
KY1105450OtherRN LICENSE
KY3004516OtherLICENSE NUMBER