Provider Demographics
NPI:1760568174
Name:WILSON, PAULA (LPN)
Entity Type:Individual
Prefix:
First Name:PAULA
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1217 TANGLEWOOD DR.
Mailing Address - Street 2:
Mailing Address - City:LEAVENWOTH
Mailing Address - State:KS
Mailing Address - Zip Code:66048-2332
Mailing Address - Country:US
Mailing Address - Phone:913-364-4419
Mailing Address - Fax:
Practice Address - Street 1:.550 POPE AVE
Practice Address - Street 2:MUNSON ARMY HEALTH CENTER
Practice Address - City:FT. LEAVENWORTH
Practice Address - State:KS
Practice Address - Zip Code:66027-2332
Practice Address - Country:US
Practice Address - Phone:913-648-6562
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS24-34961-082164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse