Healthcare Provider Details

I. General information

NPI: 1134143472
Provider Name (Legal Business Name): KRISTY LYNN WILSON APN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/27/2006
Last Update Date: 09/08/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3364 W HWY 18
MANILA AR
72442-0910
US

IV. Provider business mailing address

PO BOX 910
MANILA AR
72442-0910
US

V. Phone/Fax

Practice location:
  • Phone: 870-561-3300
  • Fax: 870-561-3307
Mailing address:
  • Phone: 870-561-3300
  • Fax: 870-561-3307

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberA01766
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: