Healthcare Provider Details

I. General information

NPI: 1801554837
Provider Name (Legal Business Name): KATRINA N WILSON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/07/2021
Last Update Date: 12/07/2021
Certification Date: 12/07/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3400 LEBANON RD
MURFREESBORO TN
37129-1392
US

IV. Provider business mailing address

423 COLETA DR
ANNISTON AL
36206-8471
US

V. Phone/Fax

Practice location:
  • Phone: 256-689-5583
  • Fax:
Mailing address:
  • Phone: 256-689-5583
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207PE0004X
TaxonomyEmergency Medical Services (Emergency Medicine) Physician
License Number3848G
License Number StateAL

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
Identifier00000000000000
Identifier TypeOTHER
Identifier State
Identifier IssuerCURRENTLY UNKNOWN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: