Provider Demographics
NPI:1255393872
Name:RYAN - WILSON, KELLIE MARIE (CNM)
Entity type:Individual
Prefix:
First Name:KELLIE
Middle Name:MARIE
Last Name:RYAN - WILSON
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:KELLIE
Other - Middle Name:
Other - Last Name:RYAN
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CNP
Mailing Address - Street 1:PO BOX 22000
Mailing Address - Street 2:
Mailing Address - City:SAN ANGELO
Mailing Address - State:TX
Mailing Address - Zip Code:76902-7200
Mailing Address - Country:US
Mailing Address - Phone:325-658-1511
Mailing Address - Fax:325-481-2165
Practice Address - Street 1:220 E. HARRIS
Practice Address - Street 2:
Practice Address - City:SAN ANGELO
Practice Address - State:TX
Practice Address - Zip Code:76903
Practice Address - Country:US
Practice Address - Phone:325-658-1511
Practice Address - Fax:325-481-2165
Is Sole Proprietor?:No
Enumeration Date:2006-04-06
Last Update Date:2020-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP111628363LW0102X, 367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
No363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX170388603Medicaid
TX8Y3124OtherBCBS
TX277003YKRYMedicare PIN
TXP74467Medicare UPIN