Healthcare Provider Details

I. General information

NPI: 1841397486
Provider Name (Legal Business Name): SARAH ANGELA WILSON-KENNELLY PNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: SARAH ANGELA WILSON

II. Dates (important events)

Enumeration Date: 09/17/2006
Last Update Date: 12/06/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1301 BARBARA JORDAN BLVD SUITE 400
AUSTIN TX
78723-3077
US

IV. Provider business mailing address

1301 BARBARA JORDAN BLVD SUITE 400
AUSTIN TX
78723-3077
US

V. Phone/Fax

Practice location:
  • Phone: 512-708-1234
  • Fax:
Mailing address:
  • Phone: 512-708-1234
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number678957
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: