=====================================================
General NPI Number Information
=====================================================
NPI Number | 1891366787
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | KELLI WILKINSON
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/01/2021
-----------------------------------------------------
Last Update Date | 04/21/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 200 PATEWOOD DR STE B260
-----------------------------------------------------
City | GREENVILLE
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29615-6328
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 864-454-2852
-----------------------------------------------------
Fax | 864-454-2899
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 300 E MCBEE AVE STE 300
-----------------------------------------------------
City | GREENVILLE
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29601-2899
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 864-522-8611
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number | APRN.CNP.0029188
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363LG0600X
-----------------------------------------------------
Taxonomy Name | Gerontology Nurse Practitioner
-----------------------------------------------------
License Number | APRN.CNP.0029188
-----------------------------------------------------
License Number State | OH
-----------------------------------------------------
Taxonomy #3
-----------------------------------------------------
Taxonomy Code | 363LA2200X
-----------------------------------------------------
Taxonomy Name | Adult Health Nurse Practitioner
-----------------------------------------------------
License Number | 30012
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------