Provider Demographics
NPI:1790404069
Name:WILSON, DWAN KRISTINE
Entity Type:Individual
Prefix:
First Name:DWAN
Middle Name:KRISTINE
Last Name:WILSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:800 COLEMAN AVE
Mailing Address - Street 2:
Mailing Address - City:ATHENS
Mailing Address - State:AL
Mailing Address - Zip Code:35611-3220
Mailing Address - Country:US
Mailing Address - Phone:256-497-5925
Mailing Address - Fax:
Practice Address - Street 1:6405 ERIC ST NW
Practice Address - Street 2:
Practice Address - City:HUNTSVILLE
Practice Address - State:AL
Practice Address - Zip Code:35810-1605
Practice Address - Country:US
Practice Address - Phone:256-497-5925
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-22
Last Update Date:2022-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant