Provider Demographics
NPI:1851097307
Name:WILSON, KELLY MARIE (LPN)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:MARIE
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 1:111 MURPHREE AVE
Mailing Address - Street 2:
Mailing Address - City:CENTERVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:37033-1418
Mailing Address - Country:US
Mailing Address - Phone:931-729-3516
Mailing Address - Fax:931-729-5029
Practice Address - Street 1:111 MURPHREE AVE
Practice Address - Street 2:
Practice Address - City:CENTERVILLE
Practice Address - State:TN
Practice Address - Zip Code:37033-1418
Practice Address - Country:US
Practice Address - Phone:931-729-3516
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-06
Last Update Date:2023-02-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN49930164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse