Healthcare Provider Details

I. General information

NPI: 1255753331
Provider Name (Legal Business Name): MARY KATHERINE WILSON CRNA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MARY KATHERINE TOLBERT CRNA

II. Dates (important events)

Enumeration Date: 01/09/2014
Last Update Date: 06/17/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

420 S 5TH AVE
WEST READING PA
19611-2143
US

IV. Provider business mailing address

PO BOX 13579
READING PA
19612-3579
US

V. Phone/Fax

Practice location:
  • Phone: 484-628-8269
  • Fax: 484-628-5163
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number100734
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License NumberRN595348
License Number StatePA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: