=====================================================
General NPI Number Information
=====================================================
NPI Number | 1285219303
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CRYSTAL NICHOLE WILKERSON NP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/10/2021
-----------------------------------------------------
Last Update Date | 01/27/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6025 WALNUT GROVE RD STE 508
-----------------------------------------------------
City | MEMPHIS
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 38120-2125
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 901-767-5864
-----------------------------------------------------
Fax | 901-767-6591
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2120 EXETER RD STE 250
-----------------------------------------------------
City | GERMANTOWN
-----------------------------------------------------
State | TN
-----------------------------------------------------
Zip | 38138-3931
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 901-767-5864
-----------------------------------------------------
Fax | 901-767-6591
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LA2100X
-----------------------------------------------------
Taxonomy Name | Acute Care Nurse Practitioner
-----------------------------------------------------
License Number | 28632
-----------------------------------------------------
License Number State | TN
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363LA2100X
-----------------------------------------------------
Taxonomy Name | Acute Care Nurse Practitioner
-----------------------------------------------------
License Number | 904609
-----------------------------------------------------
License Number State | MS
-----------------------------------------------------