Provider Demographics
NPI:1154921351
Name:WILSON, KYLEE
Entity type:Individual
Prefix:
First Name:KYLEE
Middle Name:
Last Name:WILSON
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 1:64 OAK ST
Mailing Address - Street 2:
Mailing Address - City:PENNSBORO
Mailing Address - State:WV
Mailing Address - Zip Code:26415-1284
Mailing Address - Country:US
Mailing Address - Phone:304-299-1714
Mailing Address - Fax:
Practice Address - Street 1:64 OAK ST
Practice Address - Street 2:
Practice Address - City:PENNSBORO
Practice Address - State:WV
Practice Address - Zip Code:26415-1284
Practice Address - Country:US
Practice Address - Phone:304-299-1714
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-10-27
Last Update Date:2020-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant