Provider Demographics
NPI:1740451350
Name:WILSON, KRISTEN KAROL (PMHNP)
Entity type:Individual
Prefix:
First Name:KRISTEN
Middle Name:KAROL
Last Name:WILSON
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1225 E BROADWAY RD
Mailing Address - Street 2:STE. 240
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85282-1525
Mailing Address - Country:US
Mailing Address - Phone:480-929-5100
Mailing Address - Fax:480-731-1066
Practice Address - Street 1:1225 E BROADWAY RD
Practice Address - Street 2:STE. 240
Practice Address - City:TEMPE
Practice Address - State:AZ
Practice Address - Zip Code:85282-1525
Practice Address - Country:US
Practice Address - Phone:480-929-5100
Practice Address - Fax:480-731-1066
Is Sole Proprietor?:Yes
Enumeration Date:2008-03-23
Last Update Date:2008-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAP2733363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health