MEDICARE: KRISTEN MABUS WILSON CNP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	COA 15085 NP	OH
2	363LF0000X	Family Nurse Practitioner	207724	NC
3	363LF0000X	Family Nurse Practitioner	TL20205	SC
4	363LF0000X	Family Nurse Practitioner	20205	SC

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program
2	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1831466747
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KRISTEN MABUS WILSON CNP

Provider Business Mailing Address
First Line	:	PO BOX 743070
Second Line	:
City	:	ATLANTA
State	:	GA
Zip	:	30374-3070
Country	:	US
Telephone Number	:	864-560-4304
Fax Number	:	864-560-4413

Provider Business Practice Location Address
First Line	:	380 SERPENTINE DR
Second Line	:	SUITE 200
City	:	SPARTANBURG
State	:	SC
Zip	:	29303-3066
Country	:	US
Telephone Number	:	864-560-7050
Fax Number	:	864-560-0800

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/20/2011
Last Update Date	:	01/19/2021

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