Healthcare Provider Details

I. General information

NPI: 1184034951
Provider Name (Legal Business Name): KUTTAWA CLINIC, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/02/2014
Last Update Date: 09/30/2020
Certification Date: 09/30/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

91 CEDAR STREET
KUTTAWA KY
42055
US

IV. Provider business mailing address

PO BOX 370
KUTTAWA KY
42055-0370
US

V. Phone/Fax

Practice location:
  • Phone: 270-853-8685
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number3009151
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. DEBRA WILDER
Title or Position: MEMBER
Credential: MD
Phone: 270-853-8685