Healthcare Provider Details

I. General information

NPI: 1023578846
Provider Name (Legal Business Name): WESLEY ANNE STEPHENS STUDENT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: WESLEY STEPHENS WILT

II. Dates (important events)

Enumeration Date: 03/20/2019
Last Update Date: 05/08/2026
Certification Date: 05/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 ROSE ST # C-246
LEXINGTON KY
40536-7001
US

IV. Provider business mailing address

800 ROSE ST # C-246
LEXINGTON KY
40536-0293
US

V. Phone/Fax

Practice location:
  • Phone: 859-323-6162
  • Fax: 859-257-8934
Mailing address:
  • Phone: 859-323-6162
  • Fax: 859-257-8934

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License NumberA201672
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: