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General NPI Number Information
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NPI Number | 1770551319
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Entity Type | Individual
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Provider Name | TINA L WILSON ARNP RN
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Gender | Female
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Dates
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Enumeration Date | 03/09/2006
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Last Update Date | 02/06/2012
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Provider Practice Location Address
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Address Line | 580 WESTPORT RD
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City | ELIZABETHTOWN
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State | KY
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Zip | 42701-2949
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Country | US
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Telephone | 270-765-6196
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Fax | 270-763-0397
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Provider Business Mailing Address
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Address Line | PO BOX 2609
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City | ELIZABETHTOWN
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State | KY
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Zip | 42702-2609
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Country | US
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Telephone | 270-769-1601
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Fax | 270-765-7274
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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 | 163W00000X
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Taxonomy Name | Registered Nurse
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License Number | 1072465
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License Number State | KY
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Taxonomy #2
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Taxonomy Code | 363LW0102X
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Taxonomy Name | Women's Health Nurse Practitioner
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License Number | 2609P
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License Number State | KY
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