Provider Demographics
NPI:1851747596
Name:WILSON, KRISTIN NICOLE (NP-C)
Entity Type:Individual
Prefix:MS
First Name:KRISTIN
Middle Name:NICOLE
Last Name:WILSON
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2011 4TH ST
Mailing Address - Street 2:
Mailing Address - City:LA GRANDE
Mailing Address - State:OR
Mailing Address - Zip Code:97850-2511
Mailing Address - Country:US
Mailing Address - Phone:541-963-4139
Mailing Address - Fax:541-429-6612
Practice Address - Street 1:2011 4TH ST
Practice Address - Street 2:
Practice Address - City:LA GRANDE
Practice Address - State:OR
Practice Address - Zip Code:97850-2511
Practice Address - Country:US
Practice Address - Phone:541-963-4139
Practice Address - Fax:541-429-6612
Is Sole Proprietor?:No
Enumeration Date:2016-05-12
Last Update Date:2020-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMCNP-02899363L00000X
OR202000961NP-PP363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner