Provider Demographics
NPI:1689953150
Name:WILSON, KATHRYN (KATHRYN WILSON)
Entity Type:Individual
Prefix:MISS
First Name:KATHRYN
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:KATHRYN WILSON
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:56 TUDOR LN
Mailing Address - Street 2:
Mailing Address - City:BAY SHORE
Mailing Address - State:NY
Mailing Address - Zip Code:11706-5530
Mailing Address - Country:US
Mailing Address - Phone:631-647-7095
Mailing Address - Fax:
Practice Address - Street 1:56 TUDOR LN
Practice Address - Street 2:
Practice Address - City:BAY SHORE
Practice Address - State:NY
Practice Address - Zip Code:11706-5530
Practice Address - Country:US
Practice Address - Phone:631-647-7095
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-08-15
Last Update Date:2011-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY239801-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse