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General NPI Number Information
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NPI Number | 1205504354
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Entity Type | Individual
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Provider Name | KENZLEY MALONE WILSON
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Gender | Female
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Dates
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Enumeration Date | 09/02/2021
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Last Update Date | 09/03/2021
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Provider Practice Location Address
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Address Line | 948 COUNTY ROAD 113
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City | BONO
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State | AR
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Zip | 72416-8299
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Country | US
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Telephone | 870-219-5534
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Fax | 870-203-9335
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Provider Business Mailing Address
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Address Line | 16532 HIGHWAY 18 E
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City | BLACK OAK
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State | AR
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Zip | 72414-9611
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Country | US
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Telephone | 870-243-6990
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 225X00000X
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Taxonomy Name | Occupational Therapist
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License Number |
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License Number State |
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