Provider Demographics
NPI:1770155343
Name:WILSON, KATHRYN (CRNP)
Entity type:Individual
Prefix:
First Name:KATHRYN
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8579 COMMERCE DR STE 104
Mailing Address - Street 2:
Mailing Address - City:EASTON
Mailing Address - State:MD
Mailing Address - Zip Code:21601-7420
Mailing Address - Country:US
Mailing Address - Phone:410-822-9133
Mailing Address - Fax:
Practice Address - Street 1:618 SUNBURST HWY
Practice Address - Street 2:
Practice Address - City:CAMBRIDGE
Practice Address - State:MD
Practice Address - Zip Code:21613-2546
Practice Address - Country:US
Practice Address - Phone:667-372-0228
Practice Address - Fax:410-822-9513
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-13
Last Update Date:2024-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR211652363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily