Healthcare Provider Details

I. General information

NPI: 1588968606
Provider Name (Legal Business Name): KELLY FIELDS-WILBURN NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/04/2011
Last Update Date: 09/01/2020
Certification Date: 09/01/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

610 N ONE MILE RD
DEXTER MO
63841-2539
US

IV. Provider business mailing address

200 CORPORATE BLVD SUITE 201
LAFAYETTE LA
70508-3870
US

V. Phone/Fax

Practice location:
  • Phone: 573-624-3600
  • Fax:
Mailing address:
  • Phone: 800-893-9698
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number2001026712
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: