Provider Demographics
NPI:1689812802
Name:WILSON, KIMBERLY SUSANN (APRN)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:SUSANN
Last Name:WILSON
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 2168
Mailing Address - Street 2:
Mailing Address - City:SPARTANBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29304-2168
Mailing Address - Country:US
Mailing Address - Phone:864-560-4123
Mailing Address - Fax:
Practice Address - Street 1:101 E WOOD ST
Practice Address - Street 2:
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29303-3040
Practice Address - Country:US
Practice Address - Phone:864-560-6000
Practice Address - Fax:864-560-7715
Is Sole Proprietor?:Yes
Enumeration Date:2009-01-26
Last Update Date:2021-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC3974363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
SCNP1547Medicaid
SCAA47723365Medicare PIN
SCNP1547Medicaid
SCAA47725019Medicare PIN