Healthcare Provider Details

I. General information

NPI: 1811375801
Provider Name (Legal Business Name): KIMBERLY GRACE WILSON CSTFA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/11/2015
Last Update Date: 05/11/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1155 MILL ST
RENO NV
89502-1576
US

IV. Provider business mailing address

1950 CARLIN ST
RENO NV
89503-4023
US

V. Phone/Fax

Practice location:
  • Phone: 775-982-4280
  • Fax:
Mailing address:
  • Phone: 830-313-4403
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code246ZC0007X
TaxonomySurgical Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: