Healthcare Provider Details

I. General information

NPI: 1760568174
Provider Name (Legal Business Name): PAULA WILSON LPN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/27/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

.550 POPE AVE MUNSON ARMY HEALTH CENTER
FT. LEAVENWORTH KS
66027-2332
US

IV. Provider business mailing address

1217 TANGLEWOOD DR.
LEAVENWOTH KS
66048-2332
US

V. Phone/Fax

Practice location:
  • Phone: 913-648-6562
  • Fax:
Mailing address:
  • Phone: 913-364-4419
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164W00000X
TaxonomyLicensed Practical Nurse
License Number24-34961-082
License Number StateKS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: