Provider Demographics
NPI:1609526532
Name:WILSON, KATHLEEN MARIE
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:MARIE
Last Name:WILSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:423 NW 6TH ST APT 11
Mailing Address - Street 2:
Mailing Address - City:REDMOND
Mailing Address - State:OR
Mailing Address - Zip Code:97756-1685
Mailing Address - Country:US
Mailing Address - Phone:714-603-5692
Mailing Address - Fax:
Practice Address - Street 1:1655 CAPITOL ST NE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-7845
Practice Address - Country:US
Practice Address - Phone:503-877-2815
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-24
Last Update Date:2022-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORTHW000106352374J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374J00000XNursing Service Related ProvidersDoula
Provider Identifiers
StateIdentifier IDID TypeIssuer
ORTHW000106352OtherOREGON HEALTH AUTHORITY