Provider Demographics
NPI:1023124518
Name:WILSON, KATHRYN LYNN (OD)
Entity type:Individual
Prefix:DR
First Name:KATHRYN
Middle Name:LYNN
Last Name:WILSON
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10 HENNINGS CT
Mailing Address - Street 2:
Mailing Address - City:ANTIOCH
Mailing Address - State:IL
Mailing Address - Zip Code:60002-1420
Mailing Address - Country:US
Mailing Address - Phone:847-395-0113
Mailing Address - Fax:847-395-4103
Practice Address - Street 1:2019 N RICHMOND RD
Practice Address - Street 2:
Practice Address - City:MCHENRY
Practice Address - State:IL
Practice Address - Zip Code:60050-1418
Practice Address - Country:US
Practice Address - Phone:815-385-9224
Practice Address - Fax:815-385-9285
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILU18375Medicare UPIN