Provider Demographics
NPI:1487308706
Name:WILSON, KIMBERLY T (C-NP)
Entity type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:T
Last Name:WILSON
Suffix:
Gender:F
Credentials:C-NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:901 N 7TH ST
Mailing Address - Street 2:
Mailing Address - City:WEST MEMPHIS
Mailing Address - State:AR
Mailing Address - Zip Code:72301-2001
Mailing Address - Country:US
Mailing Address - Phone:870-735-4334
Mailing Address - Fax:
Practice Address - Street 1:3481 AUSTIN PEAY HWY
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38128-3801
Practice Address - Country:US
Practice Address - Phone:901-842-3174
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-02-06
Last Update Date:2023-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AR217809363LF0000X
TN30266363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily