Healthcare Provider Details

I. General information

NPI: 1417623109
Provider Name (Legal Business Name): KATHERINE WILSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/21/2021
Last Update Date: 09/10/2021
Certification Date: 08/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1756 S LEWIS RD
CAMARILLO CA
93012-8520
US

IV. Provider business mailing address

1421 SUFFOLK AVE
THOUSAND OAKS CA
91360-3537
US

V. Phone/Fax

Practice location:
  • Phone: 805-383-3669
  • Fax:
Mailing address:
  • Phone: 410-474-2123
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: