Provider Demographics
NPI:1891855532
Name:WILKERSON, KATIE L (ARNP)
Entity Type:Individual
Prefix:
First Name:KATIE
Middle Name:L
Last Name:WILKERSON
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 534595
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30353-4595
Mailing Address - Country:US
Mailing Address - Phone:800-331-9294
Mailing Address - Fax:812-962-6425
Practice Address - Street 1:20 SAN FILIPPO DR SE
Practice Address - Street 2:
Practice Address - City:PALM BAY
Practice Address - State:FL
Practice Address - Zip Code:32909-2200
Practice Address - Country:US
Practice Address - Phone:321-725-8300
Practice Address - Fax:321-725-1555
Is Sole Proprietor?:No
Enumeration Date:2006-12-11
Last Update Date:2021-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP 3073572363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL308812000Medicaid
FLAH660ZMedicare PIN