Healthcare Provider Details

I. General information

NPI: 1346379443
Provider Name (Legal Business Name): KATHRYN MARLENE WILSON CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: KAY MARLENE WILSON CRNA

II. Dates (important events)

Enumeration Date: 03/05/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1275 SADLER WAY STE 202
FAIRBANKS AK
99701
US

IV. Provider business mailing address

PO BOX 82144
FAIRBANKS AK
99708-2144
US

V. Phone/Fax

Practice location:
  • Phone: 907-452-4101
  • Fax:
Mailing address:
  • Phone: 907-479-7017
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number34
License Number StateAK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: