Provider Demographics
NPI:1952116196
Name:WILSON, KETTIA (MSN NC-BC RN)
Entity type:Individual
Prefix:
First Name:KETTIA
Middle Name:
Last Name:WILSON
Suffix:
Gender:F
Credentials:MSN NC-BC RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15460 CANYON GULCH LN UNIT 210
Mailing Address - Street 2:
Mailing Address - City:ENGLEWOOD
Mailing Address - State:CO
Mailing Address - Zip Code:80112-4705
Mailing Address - Country:US
Mailing Address - Phone:303-901-9163
Mailing Address - Fax:
Practice Address - Street 1:15460 CANYON GULCH LN UNIT 210
Practice Address - Street 2:
Practice Address - City:ENGLEWOOD
Practice Address - State:CO
Practice Address - Zip Code:80112-4705
Practice Address - Country:US
Practice Address - Phone:303-901-9163
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-02-12
Last Update Date:2025-02-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CORN.1632281171400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171400000XOther Service ProvidersHealth & Wellness Coach