Healthcare Provider Details

I. General information

NPI: 1376245720
Provider Name (Legal Business Name): ANWULI N. ANAZIA-WILSON MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/20/2023
Last Update Date: 06/15/2026
Certification Date: 06/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

913 N DIXIE AVE
ELIZABETHTOWN KY
42701-2503
US

IV. Provider business mailing address

913 N DIXIE AVE
ELIZABETHTOWN KY
42701-2503
US

V. Phone/Fax

Practice location:
  • Phone: 270-706-5612
  • Fax: 270-706-5615
Mailing address:
  • Phone: 270-706-5612
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number61169
License Number StateKY
# 2
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: