Provider Demographics
NPI:1720205586
Name:WILSON, KAYCI DIAL (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:
First Name:KAYCI
Middle Name:DIAL
Last Name:WILSON
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:815 S PINE ST
Mailing Address - Street 2:
Mailing Address - City:VIVIAN
Mailing Address - State:LA
Mailing Address - Zip Code:71082-3353
Mailing Address - Country:US
Mailing Address - Phone:318-375-3239
Mailing Address - Fax:318-375-2755
Practice Address - Street 1:815 S PINE ST
Practice Address - Street 2:
Practice Address - City:VIVIAN
Practice Address - State:LA
Practice Address - Zip Code:71082-3353
Practice Address - Country:US
Practice Address - Phone:318-375-3239
Practice Address - Fax:318-375-2755
Is Sole Proprietor?:No
Enumeration Date:2007-04-20
Last Update Date:2023-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LARN097383163W00000X
LAAP05072363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
LA2100360Medicaid
LA3B5167720Medicare PIN