Provider Demographics
NPI:1558764928
Name:WILSON, RITA (APRN)
Entity Type:Individual
Prefix:
First Name:RITA
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 21890
Mailing Address - Street 2:
Mailing Address - City:BELFAST
Mailing Address - State:ME
Mailing Address - Zip Code:04915-4115
Mailing Address - Country:US
Mailing Address - Phone:502-907-0356
Mailing Address - Fax:502-919-9780
Practice Address - Street 1:165 NATCHEZ TRACE AVE
Practice Address - Street 2:SUITE 205
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42103-7940
Practice Address - Country:US
Practice Address - Phone:270-282-2024
Practice Address - Fax:270-282-2027
Is Sole Proprietor?:No
Enumeration Date:2014-09-30
Last Update Date:2024-02-13
Deactivation Date:
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Provider Licenses
StateLicense IDTaxonomies
KY3008962363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY7100319790Medicaid