Healthcare Provider Details

I. General information

NPI: 1174508915
Provider Name (Legal Business Name): KATHY A. WILSON ARNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: KATHY TRIGG ARNP

II. Dates (important events)

Enumeration Date: 12/14/2005
Last Update Date: 08/21/2026
Certification Date: 08/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

71 MARY ESTHER BLVD
MARY ESTHER FL
32569-1967
US

IV. Provider business mailing address

151 MARY ESTHER BLVD STE 408
MARY ESTHER FL
32569-1975
US

V. Phone/Fax

Practice location:
  • Phone: 850-301-0677
  • Fax: 850-243-0040
Mailing address:
  • Phone: 850-863-3000
  • Fax: 850-862-1621

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberARNP9162558
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: