Provider Demographics
NPI:1821634502
Name:WILKINSON, KATHY RENEE (AGACNP)
Entity Type:Individual
Prefix:
First Name:KATHY
Middle Name:RENEE
Last Name:WILKINSON
Suffix:
Gender:F
Credentials:AGACNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:990 HIGHWAY 29
Mailing Address - Street 2:
Mailing Address - City:WIGGINS
Mailing Address - State:MS
Mailing Address - Zip Code:39577-8430
Mailing Address - Country:US
Mailing Address - Phone:662-229-8129
Mailing Address - Fax:
Practice Address - Street 1:990 HIGHWAY 29
Practice Address - Street 2:
Practice Address - City:WIGGINS
Practice Address - State:MS
Practice Address - Zip Code:39577-8430
Practice Address - Country:US
Practice Address - Phone:662-229-8129
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-11-18
Last Update Date:2019-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS903609363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner