Provider Demographics
NPI:1972884674
Name:WILKERSON, KRISTIN L
Entity Type:Individual
Prefix:
First Name:KRISTIN
Middle Name:L
Last Name:WILKERSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3633 BRIDGE RD
Mailing Address - Street 2:
Mailing Address - City:SUFFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23435-1807
Mailing Address - Country:US
Mailing Address - Phone:757-686-4793
Mailing Address - Fax:
Practice Address - Street 1:3633 BRIDGE RD
Practice Address - Street 2:
Practice Address - City:SUFFOLK
Practice Address - State:VA
Practice Address - Zip Code:23435-1807
Practice Address - Country:US
Practice Address - Phone:757-686-4793
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-09-08
Last Update Date:2011-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0202205439183500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183500000XPharmacy Service ProvidersPharmacist