Provider Demographics
NPI:1780824912
Name:WILSON, KOURTNEY LYNN (NP)
Entity Type:Individual
Prefix:
First Name:KOURTNEY
Middle Name:LYNN
Last Name:WILSON
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2702 LOW CT
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:94534-9771
Mailing Address - Country:US
Mailing Address - Phone:707-427-4900
Mailing Address - Fax:707-432-2800
Practice Address - Street 1:2702 LOW CT
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:CA
Practice Address - Zip Code:94534-9771
Practice Address - Country:US
Practice Address - Phone:707-427-4900
Practice Address - Fax:707-432-2800
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-27
Last Update Date:2009-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANP18844363LX0001X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LX0001XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerObstetrics & Gynecology