Provider Demographics
NPI:1952941296
Name:WILSON, KRISTY L (RN, IBCLC)
Entity Type:Individual
Prefix:
First Name:KRISTY
Middle Name:L
Last Name:WILSON
Suffix:
Gender:F
Credentials:RN, IBCLC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:455 WILSON LN
Mailing Address - Street 2:
Mailing Address - City:WAVERLY
Mailing Address - State:WV
Mailing Address - Zip Code:26184-7172
Mailing Address - Country:US
Mailing Address - Phone:304-917-5940
Mailing Address - Fax:
Practice Address - Street 1:800 GARFIELD AVE # SDU
Practice Address - Street 2:
Practice Address - City:PARKERSBURG
Practice Address - State:WV
Practice Address - Zip Code:26101-5340
Practice Address - Country:US
Practice Address - Phone:304-424-2748
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-01-15
Last Update Date:2020-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WVL-161665163WL0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WL0100XNursing Service ProvidersRegistered NurseLactation Consultant