Healthcare Provider Details

I. General information

NPI: 1326286089
Provider Name (Legal Business Name): ANITA JANE WILKERSON CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: ANITA J KELLOGG RN

II. Dates (important events)

Enumeration Date: 02/03/2009
Last Update Date: 08/24/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

JUNCTION OF HIGHWAY 371 & ROUTE 9
CROWNPOINT NM
97313
US

IV. Provider business mailing address

P.O. BOX 358 JUNCTION OF HIGHWAY 371 & ROUTE 9
CROWNPOINT NM
87313-0358
US

V. Phone/Fax

Practice location:
  • Phone: 505-786-5291
  • Fax:
Mailing address:
  • Phone: 505-786-5291
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberR175091
License Number StateMD
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberR175091
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: