Healthcare Provider Details

I. General information

NPI: 1104576701
Provider Name (Legal Business Name): KATELIN WILDER WIXSON MD
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: KATELIN ROSE WIXSON

II. Dates (important events)

Enumeration Date: 03/25/2022
Last Update Date: 08/11/2026
Certification Date: 08/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1322 ELTON RD STE H
JENNINGS LA
70546-4100
US

IV. Provider business mailing address

1322 ELTON RD STE H
JENNINGS LA
70546-4100
US

V. Phone/Fax

Practice location:
  • Phone: 337-246-7200
  • Fax: 337-246-7202
Mailing address:
  • Phone: 337-246-7200
  • Fax: 337-246-7202

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number345986
License Number StateLA
# 2
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License Number345986
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: