Healthcare Provider Details

I. General information

NPI: 1518421106
Provider Name (Legal Business Name): KIRA WILSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/28/2019
Last Update Date: 01/28/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2715 MACKEY PL STE 135
SHREVEPORT LA
71118-2528
US

IV. Provider business mailing address

2704 SHED RD
BOSSIER CITY LA
71111-3382
US

V. Phone/Fax

Practice location:
  • Phone: 318-220-8423
  • Fax:
Mailing address:
  • Phone: 318-801-5260
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: