Provider Demographics
NPI:1932694700
Name:WILKERSON, DEIRDRE (NP-C)
Entity Type:Individual
Prefix:
First Name:DEIRDRE
Middle Name:
Last Name:WILKERSON
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 1:2814 INDIAN WELLS RD
Mailing Address - Street 2:
Mailing Address - City:ALAMOGORDO
Mailing Address - State:NM
Mailing Address - Zip Code:88310-3861
Mailing Address - Country:US
Mailing Address - Phone:575-415-1927
Mailing Address - Fax:575-488-1133
Practice Address - Street 1:2814 INDIAN WELLS RD
Practice Address - Street 2:
Practice Address - City:ALAMOGORDO
Practice Address - State:NM
Practice Address - Zip Code:88310-3861
Practice Address - Country:US
Practice Address - Phone:575-415-1927
Practice Address - Fax:575-488-1133
Is Sole Proprietor?:No
Enumeration Date:2018-06-25
Last Update Date:2020-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NMF06182120363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
NMF06182120OtherAANP NURSE PRACTITIONER #