Healthcare Provider Details

I. General information

NPI: 1184491201
Provider Name (Legal Business Name): KATHRYN ROSE WILSON NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/08/2023
Last Update Date: 01/25/2024
Certification Date: 01/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19 PIERCE AVE
FITCHBURG MA
01420-7160
US

IV. Provider business mailing address

19 PIERCE AVE
FITCHBURG MA
01420-7160
US

V. Phone/Fax

Practice location:
  • Phone: 978-577-0437
  • Fax: 978-345-4730
Mailing address:
  • Phone: 785-770-4379
  • Fax: 978-345-4730

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License NumberRN2310642
License Number StateMA
# 2
Primary TaxonomyN
Taxonomy Code163WP0200X
TaxonomyPediatric Registered Nurse
License NumberRN2310642
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: