=====================================================
General NPI Number Information
=====================================================
NPI Number | 1124818349
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KRISTEN WILSON NP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/09/2025
-----------------------------------------------------
Last Update Date | 05/09/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 323 N EAST ST
-----------------------------------------------------
City | BENTON
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72015-3869
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 501-304-5139
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2024 BERKSHIRE DR
-----------------------------------------------------
City | BENTON
-----------------------------------------------------
State | AR
-----------------------------------------------------
Zip | 72019-7612
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 501-326-1739
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | 232522
-----------------------------------------------------
License Number State | AR
-----------------------------------------------------