Healthcare Provider Details

I. General information

NPI: 1013269877
Provider Name (Legal Business Name): MS. KASIE WILSON
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/03/2012
Last Update Date: 10/03/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3509 UNIVERSITY AVE
WICHITA FALLS TX
76308-1425
US

IV. Provider business mailing address

3509 UNIVERSITY AVE
WICHITA FALLS TX
76308-1425
US

V. Phone/Fax

Practice location:
  • Phone: 940-642-8317
  • Fax: 855-822-0323
Mailing address:
  • Phone: 940-642-8317
  • Fax: 855-822-0323

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code176B00000X
TaxonomyMidwife
License Number12090011
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: