Provider Demographics
NPI:1700872009
Name:WILSON, CYNTHIA R (ARNP)
Entity Type:Individual
Prefix:
First Name:CYNTHIA
Middle Name:R
Last Name:WILSON
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 148
Mailing Address - Street 2:
Mailing Address - City:HARTFORD
Mailing Address - State:KY
Mailing Address - Zip Code:42347-0148
Mailing Address - Country:US
Mailing Address - Phone:270-504-1300
Mailing Address - Fax:270-504-1380
Practice Address - Street 1:1313 N MAIN ST
Practice Address - Street 2:
Practice Address - City:BEAVER DAM
Practice Address - State:KY
Practice Address - Zip Code:42320-8957
Practice Address - Country:US
Practice Address - Phone:270-298-9928
Practice Address - Fax:270-274-0134
Is Sole Proprietor?:No
Enumeration Date:2005-09-22
Last Update Date:2023-07-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY4410P363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY78012713Medicaid
KY0756002Medicare ID - Type Unspecified
KY78012713Medicaid