Provider Demographics
NPI:1558510693
Name:WILKERSON, KIM L (NP-C)
Entity Type:Individual
Prefix:
First Name:KIM
Middle Name:L
Last Name:WILKERSON
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:618 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:ALBERT LEA
Mailing Address - State:MN
Mailing Address - Zip Code:56007-4435
Mailing Address - Country:US
Mailing Address - Phone:507-369-5314
Mailing Address - Fax:
Practice Address - Street 1:404 W FOUNTAIN ST
Practice Address - Street 2:
Practice Address - City:ALBERT LEA
Practice Address - State:MN
Practice Address - Zip Code:56007-2437
Practice Address - Country:US
Practice Address - Phone:507-369-5314
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-09-13
Last Update Date:2020-09-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT200476-4405363LF0000X
MNR 189805-9363LF0000X
MN456363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily