Provider Demographics
NPI:1801554837
Name:WILSON, KATRINA N
Entity type:Individual
Prefix:
First Name:KATRINA
Middle Name:N
Last Name:WILSON
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:423 COLETA DR
Mailing Address - Street 2:
Mailing Address - City:ANNISTON
Mailing Address - State:AL
Mailing Address - Zip Code:36206-8471
Mailing Address - Country:US
Mailing Address - Phone:256-689-5583
Mailing Address - Fax:
Practice Address - Street 1:3400 LEBANON RD
Practice Address - Street 2:
Practice Address - City:MURFREESBORO
Practice Address - State:TN
Practice Address - Zip Code:37129-1392
Practice Address - Country:US
Practice Address - Phone:256-689-5583
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-12-07
Last Update Date:2021-12-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL3848G207PE0004X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207PE0004XAllopathic & Osteopathic PhysiciansEmergency MedicineEmergency Medical Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
00000000000000OtherCURRENTLY UNKNOWN