Provider Demographics
NPI:1679787600
Name:WILSON, STANLEY KEITH
Entity Type:Individual
Prefix:MR
First Name:STANLEY
Middle Name:KEITH
Last Name:WILSON
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1510 W 4TH ST
Mailing Address - Street 2:PO BOX 362
Mailing Address - City:COFFEYVILLE
Mailing Address - State:KS
Mailing Address - Zip Code:67337-3332
Mailing Address - Country:US
Mailing Address - Phone:620-251-1024
Mailing Address - Fax:620-251-6373
Practice Address - Street 1:1510 W 4TH ST
Practice Address - Street 2:
Practice Address - City:COFFEYVILLE
Practice Address - State:KS
Practice Address - Zip Code:67337-3332
Practice Address - Country:US
Practice Address - Phone:620-251-1024
Practice Address - Fax:620-251-6373
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-09
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS858237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist