Healthcare Provider Details

I. General information

NPI: 1932985488
Provider Name (Legal Business Name): BROOKLYN WILSON AGAC-NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2023
Last Update Date: 08/31/2023
Certification Date: 08/31/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 MEDICAL CENTER DR
HAZARD KY
41701-9421
US

IV. Provider business mailing address

512 HIGHLAND DR
HAZARD KY
41701-9439
US

V. Phone/Fax

Practice location:
  • Phone: 606-439-6600
  • Fax:
Mailing address:
  • Phone: 606-275-2693
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number4009065
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: