Healthcare Provider Details

I. General information

NPI: 1902014111
Provider Name (Legal Business Name): KARLA DEE WILSON FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/19/2007
Last Update Date: 11/23/2020
Certification Date: 11/23/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1500 DUARTE RD COH, DPS RM 120
DUARTE CA
91010-3012
US

IV. Provider business mailing address

PO BOX 512185
LOS ANGELES CA
90051-0185
US

V. Phone/Fax

Practice location:
  • Phone: 626-359-8111
  • Fax: 626-471-9204
Mailing address:
  • Phone: 626-775-3514
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number537766
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number12385
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: