Healthcare Provider Details

I. General information

NPI: 1982179347
Provider Name (Legal Business Name): KRISTYN ANN WILHELM M.ED., ATC, SCAT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/11/2018
Last Update Date: 10/11/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

925 ONE LANDON LOOP
CONWAY SC
29526
US

IV. Provider business mailing address

632 KENT LN APT 57B
MYRTLE BEACH SC
29579-4148
US

V. Phone/Fax

Practice location:
  • Phone: 843-349-4038
  • Fax:
Mailing address:
  • Phone: 586-484-2323
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number StateSC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: