Provider Demographics
NPI:1336607522
Name:WILSON, KATRINA (FNP)
Entity Type:Individual
Prefix:
First Name:KATRINA
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:36 PEMBERTON CV
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:TN
Mailing Address - Zip Code:38305-5514
Mailing Address - Country:US
Mailing Address - Phone:731-394-1145
Mailing Address - Fax:
Practice Address - Street 1:1600 ANTHONY RD
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30904
Practice Address - Country:US
Practice Address - Phone:731-394-1145
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-03-06
Last Update Date:2023-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN11001658363L00000X, 363LF0000X
GAGAA-NP001025363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner