Provider Demographics
NPI:1467847046
Name:WILSON, KIMBERLY (NP)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
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 1:213 S JEFFERSON ST STE 1006
Mailing Address - Street 2:
Mailing Address - City:ROANOKE
Mailing Address - State:VA
Mailing Address - Zip Code:24011-1713
Mailing Address - Country:US
Mailing Address - Phone:540-224-5715
Mailing Address - Fax:
Practice Address - Street 1:2900 LAMB CIR
Practice Address - Street 2:
Practice Address - City:CHRISTIANSBURG
Practice Address - State:VA
Practice Address - Zip Code:24073-6344
Practice Address - Country:US
Practice Address - Phone:540-731-2000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-04-01
Last Update Date:2022-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024172485363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily