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General NPI Number Information
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NPI Number | 1265706337
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Entity Type | Individual
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Provider Name | KRISTIN NICOLE WILMES
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Gender | Female
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Dates
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Enumeration Date | 03/06/2012
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Last Update Date | 11/10/2020
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Provider Practice Location Address
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Address Line | 800 TANZANITE LN
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City | MASCOUTAH
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State | IL
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Zip | 62258-2953
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Country | US
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Telephone | 618-567-0336
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Fax |
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Provider Business Mailing Address
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Address Line | 1465 S GRAND BLVD
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City | SAINT LOUIS
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State | MO
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Zip | 63104-1003
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Country | US
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Telephone | 618-567-0336
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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 | 363LP0200X
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Taxonomy Name | Pediatric Nurse Practitioner
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License Number | 2004020402
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License Number State | MO
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Taxonomy #2
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Taxonomy Code | 208000000X
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Taxonomy Name | Pediatrics Physician
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License Number | 2004020402
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License Number State | MO
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