Provider Demographics
NPI:1831466747
Name:WILSON, KRISTEN MABUS (CNP)
Entity Type:Individual
Prefix:
First Name:KRISTEN
Middle Name:MABUS
Last Name:WILSON
Suffix:
Gender:F
Credentials:CNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 743070
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30374-3070
Mailing Address - Country:US
Mailing Address - Phone:864-560-4304
Mailing Address - Fax:864-560-4413
Practice Address - Street 1:380 SERPENTINE DR
Practice Address - Street 2:SUITE 200
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29303-3066
Practice Address - Country:US
Practice Address - Phone:864-560-7050
Practice Address - Fax:864-560-0800
Is Sole Proprietor?:No
Enumeration Date:2011-11-20
Last Update Date:2021-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHCOA 15085 NP363LF0000X
NC207724363LF0000X
SCTL20205363LF0000X
SC20205363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC7005571Medicaid
SCNP1954Medicaid
SCSC85114746Medicare PIN
SCNP1954Medicaid